THOMAS J. DONOVAN, JR.

i1!:',

{

ATTORNEYGENERAL

TEL: (8oe) 24t-or89
FAX: (8oz) 24t-ozt4

http://www,ago.vermont. gov

JOSHUA R. DIAMOND
DEPUTT ATTORNEY GENERAL

\MILLIAM E. GRIFFIN
CHIEFASST. ATTORNEY
GENERAL

STATE OF VERMONT
OFFICE OF THE ATTORNEY GENERAL
28o STATB DRTVE - HC2N
WATERBI.IRY,VT

o567r-zo8o

November 9, 2018
Donna Waters, COM
Vermont Superior Court
Washington Civil Division
65 State Street
Montpelier, VT 05602
Re

DAIL

u. Homestead at

Pillsbury, et al

Docket No. 618-11-18 Wncv
Dear Ms. Waters,

Pursuant to the Court's Order dated November 8, 2018 enclosed please find
REDACTED copies of Plaintiffs November 7,2018 fi.lings, Notice of Appearance,
and Certificate of Service for the above captioned matter. Service of the unredacted
pleadings was perfected on Defendant's on November 8, 2018. Proof of service to
follow under separate cover.
Thank you for your assistance.
Very

yours,

Bessie Weiss

Assistant Attorney General
BW/hj
Encl.

 STATE OF VERMONT
SUPERIOR COURT
WASHINGTON UNIT

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Commissioner of the
Department of Disabilities, Aging, and
Independent T.iving,

CIVIL DIVISION
DOCKET NO. 618-11-18 Wncv

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Plaintiff
V.

Homestead at Pillsbury;
Pillsbury Manor - South;
Allenwood at Pillsbury Manor,
ELCM Homestead Leasing, LLC
Defendants

NOTICE OF APPEARANCE
PLEASE TAKE NOTICE THAT Assistant Attorneys General Bessie Weiss,

Benjamin Chater, Kristin Clouser, and James Renner, hereby enter their appearances
as co-counselors in the above-captioned matter on behalf of the Commissioner of the

Department for Disabilities, Aging and Independent Living.
Dated at Waterbury, Vermont this 9th day of November, 2018.

-

signatures on next page-

1

 THOMAS J. DONOVAN, JR.
ATTORNEY GENERAL

@r^Cmr-

By:

Benjamin Chater
Assistant Attorney General
HC2 South, 280 State Drive,
Waterbury, VT 0567 l-2020
802-24t-0L93
ben. chater@vermont. gov

ERN:
by:
ssie Weiss

Assistant Attorney General
HC 2 North-280 State Drive
Waterbury, VT 0567L-2O2O
(802) 24r-0200
be

ssie.weiss@vermont. gov

ERN:

1

by:
Clouser

Assistant Attorney General
HC 2 North-280 State Drive
Waterbury, VT 05671-2080
(802) 241-0188

kristin. couser@ve rmont. gov
ERN
by:
ames Renner

Assistant Attorney General
109 State Street
Montpelier, VT 05609
(802) 828-5e47
amie.renner"@vermont. gov
ERN: 6803

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2

 STATE OF VERMONT
SUPERIOR COURT
WASHINGTON UNIT

)

Commissioner of the
Department of Disabilities, Aging, and
Independent Living,

Plaintiff
v.

Homestead at Pillsbury;
Pillsbury Manor - South;
Allenwood at Pillsbury Manor,
ELCM Homestead Leasing, LLC
Defendants

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CIVIL DIVISION
DOCKET NO. 618-11-18 Wncv

CERTIFICATE OF SERVICE
The undersigned counsel hereby represents that Plaintiffs cover letter,
redacted pleadings and exhibits, ahd notices of appearance was served by first class

mail to the following persons
Homestead at Pillsbury
VIA registered agent:
CORPORATION SERVICE COMPANY
1OO NORTH MAIN STREET, SUITE 2,
BARRE, VT, 05641, USA

Pillsbury Manor - South
VIA registered agent:
CORPORATION SERVICE COMPANY
lOO NORTH MAIN STREET, SUITE 2,
BARRE, VT, 05641, USA

ELCM Pillsbury Management LLC
VIA registered agent:
CORPORATION SERVICE COMPANY
251 LITTLE FALLS DRIVE
WILMINGTON, DE 19808

Allenwood at Pillsbury Manor
VIA registered agent:
CORPORATION SERVICE COMPANY
1OO NORTH MAIN STREET, SUITE 2,
BARRE, VT, 05641, USA

-signature on next page-

 Dated at Waterbury, Vermond this 9th day of November, 2018

THOMAS J. DONOVAN, JR.
GENERAL

by
Weiss

Attorney General
HC 2 South-280 State Drive
Waterbury, VT 0567 L-2020
(802) 24L-O2O0
bessie.weiss@vermont. gov
ERN: 4l4l

 Y-f' S{:i? [fjie]F. ilf;L,nl
l''J.q Siilt;t I *}{ {.,iil i
t:rli,::

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STAIE UF \TENXI{ONT
SUPARIO$ COUAT
1'VASTilNGTON UNIT

I$l$ ll0t 

*1

A ) & 51 CNruL DIVI$ION
EOCIffiT X0.6t g:-r/.# do"o
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)

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Commiseioner of t&e.
rl r.r c- fr
Department of Disabilities, Asinsladd -.,-

!,

Inilependent Living,

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?tainl;iff
v.

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Homestead at Pillsbury;
Pillsbnry Manor * $outh;
Allenwood at Pillsbury Menor,
ELCM Pillabury Managernent LLC
De{endants

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COMPLAr}If ANP AITPLICATION FOR
ATPOINT .*IENT OF ESCSNM&
NOW COMES The Stat€ of Veraont, Commissioner of the Departaent of

Oisabilities, Aging, and IndeBsndet Living pureuant to 3$ Y.$.A. $ ?2S2(a) and
hereby makcs the following compl*int:
SUMIT{ARY OF

C

OMPI,AIIVT

Plaintiffbr:i:rg* thia action to appoint a receiver tg opernte three reeidential
cere facilitiee in order to prevent death or serious phyoieal nnd mental harm to

reaidente and to avert the imminent financial insolvency af these faeiliiies.
Residente in all throe faeilitiec are

*t riek of grave hare

dse ts the attions and

inactions of Defendante whieh havs resulted in oignifcani food ineoeurity, rep*ated

i

 violafions of the established standarde of health, e*fefy and r*eidsnt eare ta tl:e
dotrirnent of the welfare of the reeidents.

I.

Introduction and General Allegation* Supporting lteceivership
1.

Andrew Whito is the sole manager af the four Saet Lsko Capital

Management (ELCI\{) limited liability eompanies (LLC's) that own and oporate the
Defendant facilities {tcgether, "ELCM LLC's'1.t Since February 2018, b1r. lVhits
ha* been exhibiting increasingly abnorriral and ccncerning business practieer,

including: elosing bank acsounts suddenly and without warning io etaff; failing to
collect rent from all residente in all facilitian; failing to timely pay vendors for their
services to ttre faeilitiee resulting

vendors end utilities

in the recoipt of ehut-off notice. *od throate fi'om

t* stop serr'icee: failing to'iseue proper refunde to ueeidents

and their fanili.ca; failing to eneure that the facilities maintain propsr ctaffiug;

failing to ensure residente.receive approp*ate cari; and remaiuing incomnunicado
with his own m&nageuient arrd staff about the cauee of, ar any planned resolution
to, these profounel abnormalitios.
2. Thess patterns havo grown exponentially worse in recbnt weeks. Nnrsing

staffar"e now failing to show up for their shifts. The food-delivery yendor is failing

t The regietered owner of all three fasfities ie EICM ?illebury Managenaant ttC. However,
each fncility's license to oper*Ne.in the State of Vermont is held by s eeparate LLC. The
licenee for Allenwood at Pillsbury ig beld bv ELCM Allenwo*d Management LLC. The
license for PiXebury Manor Se$th ie held by ELCM M*nor South Management LL.,C. ?he
licenee for Homeetead at Piilsbury is held by SI,CM Hornestead Management LLC.
Hereafber, the thr*e LLC'* that hold the licensss fox ibe facilities will be rsferred to as the
"lieenrce tLC's."
A

 '. 

to make regular deliveriee due to lack of payment, and
deliveries will be rtapped

days.

"""ttl

it has indicated that

payment is recsived" Foad reserves are down ta 2 -

Reeidente are not rcceiving required as8istance

with medication

man&g€ment, and perCIonal care neede and reeideuts are experiencing increased

stre** and arrxiety over tbe *tability af the faeitity and their residsace.

Exhibit A;

G
3. Seenarios strikiagly similar to the instant matter have recently ariaen

involving facilities owned by Mr. White

il

at leaet *hree other states.? Mr. White

has failed to reqpo*d to repeated anrl urgent inquirie* &om the Depn:tment, the

Office qf the Vermont Attorney Oeneral, the State l,ong-?ern Care Ombudonann
and hie own sta{f. Exhibit B, I, J, K, &. Inlerventiou of thie Court is needed to

prevont serioue harm to reeidente and to rescue th'e facilitiee from financial ruin-

n.

Parties
4. Plaintiff is the State of Vermont, through the Commissisr:er of the

Department $f Disabilities, Agrng, and Independent Living f'PAIL and the
Department" or "the Commiseioner"). The Bepartmont is Vermont'n liconsing

Appended to thie Complnint are {)*ober 3018 court filinge initiating theae actions in ihe $tatec of
Texas and Tenneseee. The Department ie also awal€ of a *imilar actisn pending in tha $tata of
lndian*. In additios, Mr. White is in conteupt of caurt and faeing multiple sanctiona from U.$.
Bankruplcy Oourt for the Middle llietriet af terureesee for lailing ta resit praperty to a bankruptcy
eetats and failing to comply with multiple csurt orders. Exhibit I{.
2

,)

 agency as defined, by 83 V.S.A. $ ?102{5). The Depaxtment is authorized to

initiats

this action pursuant to,Title 3S, Chapter ?li subchapter 4, of the Vermont $tatutsg
Annotated.
5. Defendante are a* lbllows:

a. Allenwosd at Pillaburg ("Allenwoad"),

90 Allenxood H,o*d, Soutb

Surling$on, 'VT 05403 (Licensee: ELOM AJlenwasd Managenent LLO.
Owner: SIOM Piltebury Management LT.rC, 1424L Dallae Parkway,

Suite 650, Ila}lae, ?X, 76264.,

b.

Pillebury Manor South ("Pillsbury M&nor"), 20 Harbor View Road,
South Burlington,\lT 06403 {Licenaee: $I,CM Mnnor $outh

Management LLC. Owner: FLCM Pill*bury Managenent

tLC,

142{1

ballas Fnrkway, gldts 650, Dalla*, TX, ?5*S4.)

c" Hsmesteqd.*t Fillsbnm fHomostead"),

S

Harborview Srive, $t,

Albnns, YT 054?S (ticensee: ELCM Homestead Management LrLC.

Owncr: SLCM Pill*bury Managernent LLC, L42&l Dallas Parkway,
Suite 650, Dallas, TX, ?6954.)
$. On May 5, 2A17, the Fepartment granted liceneoe to Mr. trVhite, through

his LtC's, to operate the Defendant facilities. e{". White work* and reeides in
Dallas, Texas, and he purch*sed the three f*citities through ELCM Pillsbury
Management LLC in ?016. In the s&me transaction, he nlso purchased a fourth

 Pillsbury faciliqy, Harborview, wbish is as indepcndent living f*cilify in South
Burlington.r
?. *A,llenwood,

Pillxbury Ma:ror, and Horoe*tead are *,ll licansed *s L€vsl III

reeidential cars horcee, which rneauo they must be able toprovide "pereonal care,
delined as sseistance with meals, dressing, movement, bathing, groaning, *r $thsr
porsorral neede, or general supervisi*n of phyeical or mental well-being, including.

nursing overview and medieation ma.nagsment."

SB

V.$4.

$ ?1"02{10}tA}. Aa

of

October 9, 2018, there wero J.02 recidents requiring Level III'care across all three

Dcfendant facilitiee. 36 of those resided at Homestead, 27 resicled at Allenwood, and
39 resided at Pillsbury Manor. As of the sar$e date, Allenwood alao had 43

independent livi-ng resid'ente and Homestead bad 20. Ccunting Harborview, a total
of 247 eerrior citireus currently resid.e in the four Verusnt facilities owned by Mr.

White.

nL Juriediction
8. Tha

*ep*rtrnent is locatsd in lYaehingtcn Couaty at *80 $tate Drive in

Waterbury, VT.
9. Pursuant to 33 V.S.A. $ ??0?{a}, the Oommiseianer may &le a comp}eint

requesting appointment af a receiver in the Superiar Cor:rt sf the couaty in which
the licensing agency ie locatsd.

I Rarborview is not a nanlcd deftnd*nt in this proceeding
t{rn care &cilities as provided at 33 V.$,A. $ ?:01.

as

6

DAIL's authori$ for receivership is limited ts long"

 l,

IV

Evidence of irrmine$t dangbr of de*th or $€rious physicnl ar mental

harm to reaideuts, in violation of

Sg

10. The l)ofendant's acts and omiseions

V.S.A. $ ??09{aX2}.

prer*nt

o'a

eituation, a phyrical

conditian, *r'a practiee, method, or oper*.tion which presents imminent danger of
death or serious pliysical or mental harn to residents'i that may include imuiaent

or aclual abandonment cf the facilify.

gS

V.S.A. $ 7202{aX2}.

11. B*gianing in late Fcbruary 201"8, veud,ors for the facilities called

ting they had.not received paynent triggering the
manager's concern nnd outreach to carporate.

,See

Exhibit A" After ten days Mr
*top procersing any resident

Wtrits responded, direeting

payments for rent and nther sorvices at ali thtee of the Defendant facilities. /d. Mr.
closod the aceount for the Pillsbury facilitiee

White told

Jd. Since thoa, none

fov reasons that did noi ruake sense to

of thB renidents havs been billed by the incilitics, nor lrave they been able to pay any
money to the facilities" Id.,

see

also Sxhibits C, il, E *nd F. When resid.ents have

asked the facilities for .stat€ments of their aecounte, the faeilities bave been unable

to provide them. Residenls have repeatedly inforned Oep*rtment licenning
surveyot$ and invesbigatnre that they ars "very upset" by the faitrure sf the f;asilitiee
to bill them and by thoir inability to see the stntus cf their aceou$ts. S*e Exhibite B
and F, They fear the facilities &re on the verge of bankruptcy and they will suddenly
and withoui notice find themselves without a home. ,!ee Exhibits C, D, E and F.

rj

 12. Mr.

Y*"

has repeatedly failed to timely pay critical utilitioe end

vend.ora of the fasilitiee, iucluding Reinhart Foodser"rice, the company that d.elivers

mast af tbs food oupplies used bv the faciXties. $ae Exhibit A.
tes that

*t

Til

ane point or *nother, he recsived *hut

*ff

notices for every utility the fscilities relied sn for wat&r, electricity, *&e, etc.... fd.

Currently,

d.ue

to aaounts paat d.ue, Reinhart has put a hold on the Fillebury food

deliveries.

See

Sxhibit G. As of this liling, Pillsbury $outh and Allenwood repor"t

having just twer to th::roe dayr of food on hand" Jd. In previous weeks food delivery
was sporadic. Sometimoa the only way vendore got paid waa by the acctluntant,

contacting Mr. White's wife, who would pay the vendor with a credit card,
using his pereonal fund*. See Hxhibit

A. Facility

on Uy

food service.persannel reported

running oui of milk, and the need to start acceseing their *eerggnelr food supply.
See

Exhibit

G.

13. Mr. White hse also faitred ts issue refunds that urere due to residente or

their.families since March

201"8

at all three faeilities, Regulatior: requiro* fapilitiee

to issu6 any refunds that m*y be du*

within l5 days follawing resident discharge or

death. After one resident of Pill*bury Manor paseed away in Februnry 201S, a

rofund of g5,596.61

rrvae

due to the family. The resiclent's family confirmed on

September 2S, 201S thnt no refund had beon issued as of that date. This was *ot an

isolated incident,
14. Throughcut this 8-mcnth period,

Mr. White and his D*llas steffhave

repeaiedly ignored const*nt aad urgent attempte io *ommunicate with them.

7

 Cnrpcrate does not reepond. to the $tate regulatcr

* the Divieisn

of Lieensing and

Protection ai DAII, to the State l,ong-Term Carp Ombuds:Bpn,4 to the loeal
rnan&gers of these f*cili*ies, or ts

th*ir resideat*" Follovring is a sumlaary of effurts

made to contact Mr- White:
a

made repe*.ted desperate attempta at eontact in order for vendorrj and

utilitics to be paid. See Exhibit A.
?he phone number on all of the licensing applications {91?) 825"1308
d.oes

a

nat accept incoming calls. See Oxhibit I.

The Long-?erm Care Ombudsman's request in'an

e*ail

cent on

$eptomber ?, 2018 to communicate with reeidsnts dae to receiving
num.elous ealls from the reeidentS and familiee expreesing.their

anxiety over the non-collection of rent. Mr. Whi*e hae never re*ponded
to this s:nail. See Exhibit B.
I

An October 21, ?018 email from
about residcnt invaices and vendor payments,
has received ncl substantive response to date.

I

Roqueets f'or information

'See

Sxhibit J.

initially sent by DAIL on October 4, 2018.

DAIL has made so&e contact was able to speak rpith Mr. White *fter

The St$tc long.Tenn Care Ombudsman is statulorily mandated ta "rsprtsenl thc interesls of older persou and
persons with disrbilities under 60 years of age re*eiving long+erm tare-" 33 V.S.A. Chapter 75.

4

 thix requeet but, to date, he has not provid"ed any substantive onswerg
to the quoatione posed.
a

,See

Exhibit I.

Octolrer 22,*Ot enail and lett*r requesting financial statemente and
answers to sertain fin*neial questiona
General representing

v.

DAII

*os

an Assisterrt Attorney

hae received no response. 'See Hxhibit I{.

Kvidence nf subatanti*l and hnbitual violations pursuant to 88 Y.S*A.
$ 7202(aXB)
15. The facilities are in substantial or habitual violation af the standards bf

health, eafety, or resident care establiehed under $tate or federal rogulationn to the
detriment of the welfare of the resid"ents or client. 33 V.S,A.

$ ?20?(aXB).

16. Current and frrnner amployees., residents, and family nnembers exprees
deep concern about inadequate staffing, and a staffexodus. See Exhibits A, C, D, E.

being shor"i on

LNAs, LPNs and. RNs, requiring nutses to cover rnultiplo pooitione.at once, nnd
instances of nurses working 100-hour weeks. See Exhibit A. "By September, on

&

given shift, there would be just one charge-nurso tu eover two bui.ldinga,'i Id.
1?. Not surprisingly the quality of care provided ta the vesirtents has

del,eriarated. Ite-licensing curvsys and complaint investigatione conducted by DAIL

at the three lieensed facilities have resulted in many citsd deficiencies. The
following are examples of somo af the deficiencies cited:

r'1

 a

De

ath of a resident. Whea a.recident dien unexpeetedly, or witkin 48

'houre of a fall or iqjury, the lieensed sball sond a report to the licensing
agency. CVR 13-110-009 5.1?.

o

The facility failed to report the unexpected death of,a rrosident

who died ae a recult.of injuries eurtained. dlrring a fallat the

fecitify The resid*nt experienced two falls on 911118 ans in ths
morning and one at 4 p.m. The resident was found lyrng on the

fall

iqr

their r?om with the hcad against the wall&aeebosrd

heater. The resident was sent to the hospital, diagnosed with
cervical spine fracture* and pulmon*iry edema. This rseident
died as a rcsult of iqjuri*s on Sl4/1S. Sxhibit L.
a

Failure to meet poreonal, nur*ing, and medical care needs. J7., at 5.$,
o

Staff {ailed to

effe

clively monitar a resident eomplairring of ill-

heatth and, due to that fsilqre, the resident failed to raceivs
tinrely treatment requiring her adrnission

Np

tbe emergoncy

department via ambulance. Upon admission the ED found the

re*ident to have low axygen levels and a brief soaked with urine
and feces that'dis:ntegratef when the SD nurse touched it.

Exhibit L.

* Staff failcd to manitor a resident at risk fsr bsnrel ccmplieations
until a nurse sur\rsyor brought to their attention that

t0

 documentation ehowed the resident had gone for 10 days

without a bowel movem.ent. Exhibit M.
t

Failure tc sversee a vrritten plan of earc, Id,, at 8.7.

o

$tafffailed to update a.reeid.enf,c cars plan to addrese the
resids{rt'e in*reased fnlle. ?hs reeident etryerienced 5 fal}s,
inctruding two *nlle with minor head injuries bctrveea 8l1ll"8 and
10/1118.

I

Exhibit L.

F*ilure to provide a sufficient number of q*alifred porronnel, Id, at
s.r1
o

For at least, *ix day*'in $epteuber tbo Llpm-?am charge nurse
was required io coyer'th* ehi* f*r Allenwood and Pillebury
Soath. Sxhibit N.

.

Failurs tc raport abuee,"negloet, or exploitation,Id,, at S.18

o

Tbe executive director qf ihe faci[ty admitted thc

faillre to

repori to the lieensing ag€ncy or the palice the au*pected
diversion of fentanyl patches pr*scribed for a rssident. Exhibit O.
18. On October 1g, 2018, the Department impoeed a ban on admissions on

Manor $outh for the facility's failure to correct violations that wore eited in the July
12 Statement of Deflcieneies. See Exhibit P.

tl

 19. On Novenber 6, 2018 the Department iaposed a ban on adsiesisns an

Allenwood for the failure to correct violations cited in the resulte of the Oetober
2018 survey and the failure to eubmit a eampreheusive plan of carrection for

defieiencies identified during the October 3, 2018 inve*tigation.

,See

S,

:

Exhibit Q.

VII. Evidense af financial instabili.ty *.nd potenticl insolveney pursuant to
$s v.S.A. $ ?zCIs(axa)
20. The facilities have been given no access to a bank accpunt since February
?t)18. See Sxhibit A.

2L. Rent payment fxom residdnts from all ftcititibe have nat been collected
since Februa.ry 9018. ,Sce Sxhibit A.

?2. Fr.om beginning in Marsh 3018 and continuing through $eptembgr 2018

the facility stcpped paying vendors arith any regularity,

,See

Exhibi{A.

23. Shutosnotices for m4jcr utilitien at the facilities have been received at
somo point during the course of the last several months. ,See Exhibit A.

24.Thefood vendor will no longer d.elivery food and there is only a two- to
three-day supply. See Exhibit G.
25. Combined, the facilities owe Reinhari, the f,md vendsr, $5$,4S4.9d, cf
whieh $1$,888.64 ie paat due.

,Ses

Exhibit

G.

26. There is only $t00.00 rem*ining in petty castr. Exhibit G.

2?. Mr. White has failed to provido the requested assurances to the
Departrnent and the Office of the Yerraont Attorney Gensral that the licenses are
solvent.

',4

 PRAreS 3OR AELTET
WHEREFORE, the St*te of Vermont reapectfully requeete tbat tbe Court

'A.Appoint a reeeiver from the liet of recomm+nded receivers ettached
herewith;
B.$et a reasanable canpensation for the receiver;
C.Order aecountinge &sm the rtceiver;
D.$chedule and hsld a heariag on the merits of the application within 10
days per 33 V.S* ', $ ?204(aXl);
E.

Grant injunctive relief includ.ing enjoining the defendarile, tp pre*orve

all recsrds and a*eets, tnngible and intangible, of or pertaining to ihe
Defeqdant's residential care homec, and delivor eaid records and assete
to the receiver without diminution except as sBecifieallsr uuthorized by

the reeoiver, and;
F.Arnrard the $tate sucb other relief ae thie

*oult

deems;:p*t and

appropriate.
$igned and dated at Waterbury, Vermont this

?tb

day of Novennber 2018.

Keepectfully submitted,

MONICA CASSNTA HUTT
COMMI$SIONEA" DSFAA"MEN? OF
DISABIIITISS, AGINE,
ANP INDEPENDENT LIVING
thraugh c*un*el
THOI\{AS J. DONOVAN, JR.
ATTORNEY GPNENAL

I;J

 t

By:
Bessio Tlleies

Acsistart Attdrnoy Gsaeral
Hg 2 $enth
980 $tats Drivs

lfiIntorbury, Yf 06$?1-gS201
FOA 941;01S4
sRN ,*14r

:{.

 STATE OF VERMONT

SUPERIOR COURT

CIVIL DIVISION

)

)
)
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)

)

AFFIDAVITOFThe undersigned states the following under oath and upon porsonal knowledge:

1. My name is

I am over 18 years of age, of sound mind, and am

capable of making this affidavit, The facts stated in this affidavit are within my
personal knowledge.

2.

I reside at

3.lreceivedanAssociate'sdegreeinaccountingf'o[in2a17'
4.

From October ZA1/ ,oMay 2017,1 worked in operations and accounting for Larkin

Hospitality ("Larkin"), based in Burlington, VT. At the time, Larkin owned the Pillsbury
Senior Living facilities: Pillsbury Manor South, Allenwood, Harborview and
Hornestead (together, the "Pillsbury facilities"). lfirst provided accounting services to

the Pillsbury facilities in January ZAfi in relation to the sale of those facilities from
Larkin to corporate entities owned by Mr, Andrew White.

5. ln May 2017, when the purchase

was complete, East Lake CapitalManagement

hired me to be the Pillsbury facilities'
My job

6,

duties included:

L

 a.

Providing residents with timely and accurate monthly billing, and account

stalements;'

b. Collecting

residents' rent checks, each month, and processing them;

c. Entering and reviewing accuracy of monthly ACH payments from residents;
d.

Receiving vendor invoices and inputting the amounts-owed and payment-

due-dates into a centralized accounting program so that corporate could pay
vendors as appropriate. Verifoing the accuracy of invoices and products
received;

e.

Being a liaison to vendors regarding their invoices to us and our payments to

them, including following up with our corporate headquarters in Texas
("corporate"), where Andrew was based, if Vendors weren't paid in a timely
fashion;
f

.

Reviewing and verifying employees'hours worked and, on a biweekly basis,

transmitting repods of those hours to corporate so that corporate could pay
staff as appropriate;

g. Performing HR responsibilities, including lhe on-boarding and entry for newhires and calculating and inputting for review all pay increases;

h. Establishing

and negotiating vendor relationships and payment terms, to be

approved of and signed off on by Andrew, with 30-day payment terms as

dictated by Andrew;

i.

And, at month's end, finalizing the Pillsbury facilities' ledger and conducting a
general financial review of the facilities' operating profit and loss stiatements
with the Pillsbury facilities' executive directors.

2

 7.

From May 2017 to Feb 2018, the financial systems of the Pillsbury facilities were
generally functional. Residents were invoiced monthly, with rent payments
processed in a timely manner either via desktop check deposit or processing of ACH
payments. Vendor invoices were processed promptly and paid in a timely manner.

And the payroll syslem was likewise timely and accurate. At the time, Pillsbury

.

facilities' money flowed into, and out of, Wells Fargo bank accounts, with all checkwriting and, in the case of payrotl, wire transfers, being performed out of the
corporate office in Dallas, Texas ("corporate").

8.

Towards the end of February 2018,1 began to receive calls from vendors slating
they had not received payments for invoices that were due. By performing a simple
search in our centralized accounting program, I became aware that checks had not
been issued for over a week. This was irregular and concerning, I initially expressed
my concern to

I

the Executive Director of the. South Burlington Pillsbury

locations. Over the next several days, lthen sent multiple emails, and made multiple

phone calls, to corporate to ask about what was going on. At lhe time, there were
several people in the corporate office that I spoke with regularly regarding questions
and concerns:
and Andrew himself. For ten

days, nobody in corporate answered a call or email of mine. I was concerned about
the company's financial health.

9.

Finally, Andrew responded to me though an email inviting me

andl

to join

a "GoToMeeting" the next afternoon. We did, and, during that meeting, Andrew
explained thal a corporate'lT" employee had downloaded a certain program on his

3

 work computer, and lhat he (Andrew) was concerned that this program was capable
of "infecting" the company's computer network. Andrew said that because there was
an open portal between the company's computer network and its banks, he had
severed the link to avoid infecting the bank's systems. ln severing this link, he
effectively froze our bank accounts. Andrew reiterated this explanation with
additionaldetail multiple times going forward. He also shared it with the Pillsbury
community at large on June 17h,2018, in both an all-staff meeting and a meeting

with Pillsbury residents and their families.
10.

During that "GoToMeeting" catl, Andrew also made a point to represent that East
Lake was in a sound financial position. He went so far as to show us PDFs of bank

statements allegedly reflecting his different accounts and balances for the Pillsbury
operating, ownership, and leasing entities, as well as similar accounts for East
Lake;s locations in Tennessee, North Carolina, and lndiana. He also included the
corporate operating and "fund" accounts, all of which he claimed added up to
approximately $89 million. The documents that were shared were .pdf scans of bank
statements with no clear dating, and not "live" documents available from the Wells

Fargo banking software.
11

.

Soon after the "GoToMeeting," sometime in late February or early March, corporate
directed me not to process residents' rent payments, as the company had no
operaiing bank ascount in which to receive them. Andrew explained this oddity by
placing the blame with Wells Fargo. He made multiple statements to the effect that
they were solely at fault for the delay in getting the accounts operational.

4

 12,At the same time, corporate also directed me to cease monthly invoicing of
residents. Without deposit capabilities, each resident's ledger became inaccurate in
our accounting system, and any attempts to invoice a resident would have resulted
in a compounding statement of what was owed. This was deemed to be misleading

to the residents so we were told to not issue any invoices.
13.This lack of invoicing and processlng of payments caused a great number of
residents to express their anxiety and concern to me directly. From March until

I

resigned in September, I roulinely received 1}-z}calls a day from concerned
residents and families regarding this irregularity. Concerns centered on how
residents were to resolve these rapidly growing balances, and whether the company
could continue to function without receiving rent revenue.
14.Of course, some residents continued to submit rent checks to me. When that
happened, I asked corporate what action(s) I should take to secure and/or deposit
these checks. I volunteered to overnight the checks to Dallas, as they claimed to still
be able to access the Wells Fargo accounts at physical bank locations. Andrew told
me that these actions wduld be unnecessary and advised me to keep the checks
secure on the premises. When I told him that we did not have a safe on-site in the
accounting department, he told me to lock them in a.drawer.

l5.Without an operating bank account, corporate was also unable to pay checks or
make AGH payments to vendors. As a result, during Marsh 2018, no vendors for the
Pillsbury facilities were paid by check or ACH, the primary methods of payment prior

to February of 2018. I recall that internet service was disconnected for lack of

5

 payment, at that time, and that seruice was ultimately restored only after an East
Lake employee paid the vendor with a personal credit card.

16.8y the end of March, I had noticed that neithe

I

\were responding to myemails to corporale anymore. I later found out that

Andrew had fired

I

in February and

!

in either March or April. Around this

time, Andrew mandated that all communications and questions regarding billing,

vendorpaymentsorinvoicing,godirectlytohim*it[andAndrew'swife,
copied.
17. Towards

the end of April, Andrew told me that new accounts had been established

and funded with JP Morgan Chase. He stated that they hoped to have check

payment capabilities up and running by the beginning of May, with resident invoicing
to follow soon thereafier. I was told to share this timeline with residents and vendors
when approached. ln the meantime, corporate directed me not to process rent
checks, not to invoice residents for back-rent, and to stop entering vendor invoices
into the company's accounting system. lnstead, for reasons that weren't explained to

me, they requested that I scan them vendors' invoices throughout the week and
manually track the amounts due, payment due dates, and payments made on
spreadsheets, which I did,
18. From March 2018 until I resigned in Septemb er 2018, a new trend ernerged:

corporate stopped paying vendors with any regularity. Corporate attributed these
sporadic payment issues to the manual nature of payment processing: without a
centralized accounting system and check-writing capacity, payments could only be
made by manually initiating wire transfers or via credit card over the phone.

5

 Sometimes corporate would pay a vendor on time. Sometimes it would fall three
weeks behind. Under the guise of "prioritizing corporate bandwidth," the norm
became that corporate would only pay vendors in extreme circumstances, like when
a vendor had communicated to us that il would be cancelling services unless
payment wss rendered that day. At one point or another, I received shut-off notiees

for every utility the Pillsbury Facilities relied on

-

water, electricity, gas, etc,

19.To compound these problems, during this time period
in September

- March 2018 until I resigned

- corporate, and particularly Andrew, were generally incommunicado,

Andrew would not respond to my phone calls and emails for weeks at a time. This

was particularly problematic becauqe he required that he or his wife approve all
vendor payments and have corporate transmit these payments to vendors, not me"

!

was difficult to reach, as well, Even if I reached

guarantee

that!

!

though, there was no

could reach, or that I would ultimately hear back from, Andrew.

20.As a result, whon vendors contacted me because they hadn't boen paid, I had an
extremely difficult time causing corporate to pay them, To

get!

attention, I had to barrage them with phone calls and emails

-

or Andrew's

sometimes muttiple

times a day. Typically, I was only successful in reaching them if a vendor was
threatening to shut off service immediately and my communication to them
underscored as much in the most urgent of tones. Both Andrew and

!

voicemail

boxes would routinely be full or their phones would be shut off. Sometimes the only
way to get a vendor's bill paid was tg

callf

Andrew's wife, hope she answered,

and give her the name of a collections percon she could call with a credit card.

7

 Sometimes I paid vendors using my own personal check or credit card, hoping that
Andrew would reimburse me.
21.1 was particularly anxious about food vendors not being paid in a timely way. Our

primary food vendor was Reinhart Foodservice, On severaloccasions, corporate fell
behind in payments to Reinhart and the vendor stated that, without immediate
payment, they would not be able to make the next planned delivery. This was
incredibly stressfulfor me. I worried significantly about the residents'welfare. ln
those instances, I would call

Andrew.ld

I

over and over, leaving messages for

someone to "please answer" and send a wire for the needed amount. On some of
these occasions, despite my repeated efforts to get corporate to respond to
Reinhart's requests, corporate still did not pay them in a timely fashlon. During the
Spring and Summer of 2018, when I believed a delivery would actually be delayed,

I

would contact Reinhart directly and ask them to deliver despite Andrew's lack of
payment, wilh proniises of full remittance in the following days. On occasion, they

would. By the Fall, though, on multiple occasions, despite my pleas to Andrew for
payment, Reinhafi had skipped deliveries to the properties due to lack of payment.

As a result, I lost comfort in continuing to ask them to deliver despite nonpayment,
as I lost confidence in the ability to ultimately garner payment for Reinhart from
Andrew.
22. Meanwhile, throughout these months

- March to September - Andrew continued to

make promises to me that our bank issues would be resolved; that we would soon
be able to start invoicing and processing rent checks again;that we would soon
have new systems and corporate staff in place to ensure timely vendor payments. ln

8

 fact, at one point in

August,I

called me lo tell rne that corporate had actually

begun the process of billing for rsnt and that, going forward, lwas to have no
involvement in the production of invoices for residents.
23. But nothing ever changed. Rent was n6ver invoiced; checks were never processed.
By the time I resigned in September 2018, I had last invoiced Pillsbury facilities'

residents on February 20,2A18 for their March rent. Further, I had seven months of
uncashed rent checks locked in my desk drawer, many of which were stale-dated
and now incapable of .being processed. Timely payments to vendors had only
become increasingly difficult to obtain.

24.During these months, Andrew also made promises to.residents that he failed to
keep, For example, in June 2018, Andrew visited the Pillsbury facilities and
assembled Pillsbury residents and their families for a meeting, ln that meeting, he
promised them that all invoicing would resurne by August 1'r, and that he would
provide a mass communication to the entire community, including those that were
unable to attend the rneeting, laying out the specifics of handling all back-rent
payments and providing a clear explanation of all the events that precipitated the
banking issues, During my time at Pillsbury, that communication was never sent.

25.Also disconcerting, between March and Septernber 2018, in addition to problems
collecting the rent, paying criticalvendors, and meeting promises, Pillsbury's
facilities were becoming more and more understaffed. For example, after our former
Executive

DirectorJ

direclor, Andrew asked

I

left her position in May, rather than hire a new full-time

and I to serve as Co-Executive Directors of the

Pillsbury facilities while continuing our pre-existing full-time responsibilities,

9

 (Previously,I

of Homestead at Pillsbury.) Oddly,

had been the

Andrew had not asked us whether we were interested in these positions. Without
warning, he simpty announced that he had appointed us to the positions during his
June in-person meetings with Pillsbury facilities' staff and residents. Thus, from that
tirne fonnrard, in addition to performing my accounting responsibilities, I was asked to
help oversee multiple other depafiments and HR for the Pillsbury facilities.

26.We grew short on caregivers, as well

*

LNAs, LPNs and RNs. We had instances of

nurses working 100-hour weeks^ We had instances of nurses covering for multiple
positions al once, For example, during one shift at a given building, we would ideally
have two qualified caretakers dispensing medicine and one charge-nurse free to
respond lo calls and resident issues. By September, on a given shift, there would be

iust one charge-nurse to cover two buildings, and this nurse would be responsible
for dispensing medication at one of the two buildings, as well. This meant that while
the nurse was dispensing medications in one building, there was no charge-nurse
readily available to respond to calls or issues that suddenly arose. ln terms of
incidents in which short-staffing led to the threat,of harm or actual harm to a

resident, I would refer to the Department of Disability, Aging and lndependsnt
Living's {DAIL} citations and reports of our facilities as accurate records of these
instances.

2T.Weconsistently had difficulty hiring new staff, as well. I heard from staff in
Community Outreach that few people were responding to itds for nursing
department positions and that, during several interviews, interviewees had asked

10

 questions about whal was going on with Pillsbury in terms of ils ability to rneet
various kinds of financial obligations.
28. Ultimalely, given our significant staff shortage and extreme difficulty hiring new staff

on our own, I concluded that the Pillsbury facilities could only develop an appropriate
staff corps through use of a third-party stafftng agency. Accordingly, sometime in
July, I and some of my colleagues pursued the idea of signing a contract with a thirdparty vendor to provide nursing staff to our facilitles. I proposed this idea and a few

vendor options to Andrew through email. He did not respond. When DAIL visited one
of our sites in August, they raised understaffing concerns, as they had done once
before. ln response, I emailed Andrew and said that I needed to talk to him about a
variety of issues, including staffing. I rnentioned, in the email, that I had sent him a
staffing proposal two to three weeks ago and hadn't heard back from him. Toward
the end of August, he called me back. ln a brief conversation, he said that third party
staffing agencies "killyour rasidents" and he would "never sign."
2g.When Andrew said no to this proposal, lfeli like lhe environment we were lrying to
take care of people in was significantly compromised, with no possible solution in
sight. I felt utterly helpless. I genuinely didnt know where to turn.
30.Afier careful consideration over 2 weeks, I resigned, giving one month's notice.

I

concluded my work for the Pillsbury facilities on
DATED at

Vermont,

2018.

By:

STATE OF VERMONT
CHITTENDEN COUNW, SS
appeared and he
L .dayof No., ,2018,
are made upon his own personal knowledge,
statements
above
that
the
-ged
information, and belief, and in so far as upon informalion and beliei he believes them to be true.

At /h^{,}.#"/. this

act<io

11

 STATE OFVARMONT
SUPERIOR COURT

)
)

CIVIL DIVISION
DOCKET NO.

)
)

State of Vermont,
Comrniseioner of the
pepartment of Dieabilities, Aging, and
Independent Living,

)
)
)
)
)
)
)
)
)
)
)

Plaintiff
v.

Homestead at PilleburY;
Pillsbury Manor - South;
Allenwood at FillsburY Manor,
Defend,ants

AEEIpiyIl-og LoN0-'rEn M 0ARE OMBgr"rSMAw
The undersigned statee the following under oath:

1. My Bame is Sean Londergan. I

am over 18 years of age, of sound mind, and am

capable uf rnaking thie affidavit,

I am the Stnto Long-Torm Care Ombudsman

and Dire6or of the Offrce of the State Long-Term Care Ombudeman' I have held

this position since MaY 1, 2Q17.

l.

The eluties and responsibilitiee of the State Long-Term Caro Ombud*man and

their office are provided in 33 V.S.A. Chapter ?5, and the Older Arnericans Act

*t

42U.S.C. $ 3068g. Broadly, its statutory mandate is to'lrepresent the

intereste of older persons and persons with disabilities under S0 years of age
receiving long-term care." As part of that mandate long'term care facilities must

provide the Ombudsman and represontatives of the Office access to their

1

 facilities and to the individuals for whorn they provide long-term care,

v.s.A,

$ 7504

See 33

(bxz).

3. Pillsbury Manor South,

Allenwood at Fillsbury Manor in South Burlington and

Homestead in St, Albans are Jicensed reeidential care homes with the same
corporate otryney, EICM. Harborryiew at Pillsbury Manor is an independent

living eommunity adjacent to Allenwood and aleo owned by ELCM. It is not

a

licensed residential care facility but ite residents are elders who are entitled to

the evening meal at Allenwood.

4. Cugently 24? people reside irr these facilities,

they comprise an essential part of

the systcm of care in \lermont.

5. Beginning in August

of 2018 my office has received at least 18 comrnunications

from the re*idenis, their families, and staff of all 4 facilities reporting similar
complaints anrl conce rns. At first the complainants were primarily ccncerned

that they had no1 been invoiced for rent since March ?018. More recently, the
cornplaints includ.e ooncerns about a decline in ser:vices and staffing lev-els.

6.

Due to the nuraber of complaints that my office leeeived,

I emailed the owner of

the faciiities, Andrew White of ELCM, on September ?, 2018 (email attached).I

ilformed him that the failure to collect renl for, what at that time was 7 months,
loft a number of individ,uals very rnuch nt unease about the future of each of his
facilities. I let him knsw that the residents, and those concerned about their
well-being, felt that at any moment they will be left without a home. I knew from
eommnnications with residents, relatives, and etaff that, he had visited the

2

 facilities on oue occaeion during' t;he summer and told staff and reeidents that
the probleme with invoicing and billing would be corrected
1tt; but

n<l

later than Augusi

it was now September and the issue had not been correeted. I requested

that he directly communicate with the resiilents to address their concerns about
the long.term viability of the facilities under his ownership. Finalty, I rcquested

if he was unable tc resolve the iesues and eneure that the facilities would remairr
open for the foreseeahle future, that he inform the reeidents that all Vermont

regulatione would be followed were hc to discnntinue all or part r:f the operations
of the facilities. Mr, White has not responded in any way to rny email.

It ie my

understanding that Mr. White has not communicated with the residents as I
requc'stcd.

7.

Now calls and emails with carnpiaints and concerns about these facilities are
coming into my office more frequently. ?hey include: a med tech calling to say
she is afraid for a resident's r*afety because of low sta{f to resident ratios; the

Executive Director of the Comnrunity ofVermont Eldess (COVE) contacting me

.

with the complaint of a resident's daughter; and

a pcrsonal duty care giver

at

Alienwood called with rnultiple concerns about low staffing and lack of nursing
oversight for residents, including those reeidentt? on hoepice.

8.

To this point, Mr. White has shown rne no indication that he intends to remedy

the issuee that regitlents o{ his facilities have been, and contintie to, experience.
Therefore, to plotect the health, safety and continuity ofcare for these residents

I support the State's request

fori the appointrnent of a receiver. Due io all the

3

 uncertainty Burrounding the operation of ths four facilities, coupled with the
unreepensivenees of Mr. White, I believe a reeeiver is noceseary to protect
residents

fton the

adverse health effects that would be caused by the abrupt

transfer of the reeidents to other facilities, Critically, Vermont lacks the in-etate
caBacity to find suitable placenants for all of these reeidents should the facilitiee
suddenly cloee.

DATED at

$r,1,,'nJ!.tr,4

,

Vermont, this

fu

tlay of

All,r* w 20r8.

STATE OF VERMONT

CHITTENDEN COUNTY, SS,

o, ?Uflnittthia

*uv

of

NW

, 2018,

lfrrn L*&r$',porsonalty

appeared and

lhe acknowledged that the above statements are made upon her own personal
knowledge, inforrhation, and belief, and in eo far as upon information and belie{ ehe
believes them to be true.

Notary Public
My Commission Expires: 2lLAl79

4

 STATE OF VEN,MONT

SUPEBIOR COURT

CIVIL DIVISION

)
)

)
)
)
)

AE]r'IDAVITOThe undersigned ,ctates the following under oath and upon personal knawledge:

1. My na$re i* I,I

I am ovev 18 years of age, of sound rnind, and arr

capable of making this af8davit. The facts stated in this affidavit are within my

personal knowledge

2. I reaide

rtll

!.,
I

3. My mother ir I
Sr:uth Burlington,

4. I have Power

\II"

williston,

ffi,

She resi'ile*

0s495.

a[atlenwood,

90 Allen Road,

She is 93 years old.

of Attorney for my mother.

I am responeible for all of hev finarrces,

I also help ber navigate medical decisions, I visit her at Ailenwood
a week and speak

once or twice

with her by phone every other day.

5. Generally, my mom is elear-minded.

However, she is starting to have memory

rssues.

6" My

concerns about Allenwood started in March of this year, when

I didn't

get a

monthly bili from them. Then in June, my March rent payment was redeposited

into my bank account with no explanation from the bank or Allenwood. I called
Allbnwood's accountant to ask what had happened. He said that, they had moved
1

 to a ne'qi accounting system, hacl changecl banks and were not yet ready to take
deposits, This got sre wondering about the strength of this business, so I eiarted

to pay closer attention to the level sf oare my mom was getting.

7. Right away, starting

around June 2018, I notir:ed that staff were leaving at high

rates. Faces I used io see all the time I didn't $ee anymore. The charge-nurse

'

who took care of rny mom -- and who my mom felt so strongly about and trusted
-

-

left in October" Nurse aids anrl med techs have been changing. The d.irector

has been replaced with an interim director. 'fhe accountant is gone.

8. During this fime, I have also observed that key people who tcok care of my mom
were pulling doul:le and triple shifts. Relatedly, we are starting to see mistakes
get made. For instance, last week Iny mom tcld me that her nighttime
medicinee, inclutling anli-seizure pills, were delivered houvs after they should
have been. That caused my wif'e and me great concern.

g" Between the financia]
that I'm watching

issues ancl the increasing staffing and cave issues, I feel

a very steady undermining of an operation. This brings me

great uncertainty" Sorne of my biggest fears are what could happen to my morn

if

lhere is not enough staff support, for her in a moment wheu she needs it. This
keeps me up at nighl..

10.Iu February of this year, in the mi.ddle of the night, my mom had a fall, She rang
her bell, and staff camc to her immed.iately. At first, ehe tolcl them she was fine,
and so they left. But within twenty minutes, they checked on her again and saw

that

she was not okay. They called 911 and got her to the ER

2

right away. By the

 tirne slre got to the hospital, she was having seizures. She had broken her hip
and ended up [eing in rehab for months for her hip and her seizures"

11.Had staff not angwered lhe bell l;hat night, had they not come back in and
cheekeri {rn her, had she not gotten the attention she needed in a roasonable

ar:rtiunt of time, she rnight have passed. I worry that the nexi tirae, they mighl,
not show up.
12.The other thing l,hat scales rne ie if there is a fire. With the continual

understaffing, I do not know how they would get all the residents out in time.
13,

Far my mom, all of this has created a level of uncertainty that she ts not going to
get taken care ofproperly.

It wears on hcr. I know that

she does not like to

cornplain, so I fear ehe is more affected by this than she is letting on.
14.

Reing the person that is supposed to protect her going lbrward, I say to myself
on certain days, I have failed my moln.

l tried to clo due dili.gence in finding this

rcsi'deritial care home far her. I entered into a good faith agreement with the
facilil,y that they woultl take carb of her. Bul I am now at a point where I feel ihe
dangers to my mom of staying there are too high. I f'eel that I need to move her
before something terrible happens.
15.

Lastly, I am also very concerncd for other residents in this situation tlrat do not
have someone to look out fbr them and have limited abiiities nn their own.

3

 DATED at

e*tflvil-,

Vermon

2018.

STA?E OF VFNITNONT
WASHINGTON COUN?Y, SS.

EY d uyuf Liot,.*,201
and she hcknowledged that the ahove
knowleilge, information, and belie{ and in so far

At ffb.a?.\.c/tiri

s

to be true"

Pu

My Commission Expires:S -tO'I q
KAREN FARN sw0 RTH

Notary P ublic
VERMO NT

4

personally appeared
are
upon her own persbnal
as upon inforrnati*n and belie{ she

 STATE OF VERMOI\rT
SUPERIOR COURT

State of Vermont,
Commiseioner of the
Department of Dieabilities, Aging, and
Independent Living,

)

CIVIL DIVISION

)
)

DOCKET NO.

)
)
)
)
)
)
)
)
)
)
)
)

Ptaintiff
v.

Horuestead at Pillsbury;
Pillsbury Manor - South;
Allenwood at Pillsbury Manor,
Defend'ants

AFTIDAVITOFII
The undersigned states the following und"er oath and upon personal knowledge:

1. My narne ir I

I am over 18 years of age, of sound mind,

I

and am

capable of making this declaratian. The facts stated in this affidavit are within

my personal knowledge.
AIIenwood

2. My

parents,

I

and

I

I

are residents of Allenwood, an independeni

Iiving and residential facility located at 90 Allen Road, South Burlington, VT
05403. They live in Apartment

3.

and have lived there since June of 2018.

They have not received an invoice since residing at Allenwood.

4. Their rent
5.

I

is approximately $4,000.00 per month.

Rent is supposed to be due once a month.
1

 6.

No payments have been processed since they have reaided at Allenwood.

?. I have raised thie issue with several employees but have not received

a definitive

anBwer.

L

I attended a meeting held at Allenwood in July

of 2018 where the owner

addressed the residents. He stated that the issue was with Wells Fargo and that

they would be changing banks. He further stated that they would receive an
.invoice

no later than August I", 2018 and then they would stagger paymonts so

there would not be a large bill.

9. My parents have ctill not received an invoice.
10.My parents do not have long term care insurance or Medicaid.
11.I have additional concerns regarding staffing and the dining room sorvice.

l2.There has been a lot of turn over and roles and responsibilities have to be
distributed.
13.

Several individuals have resigned including the activities director and

markeiing/business director,

l4.There are only two servers in the dining roorn, and the facility has gone to a
buffet served from 12:00 PM until 3:00 PM for the "main" meal, which my mom
misses because she is visiting my father in the hospital at that

time. The buffet

servie€ has been happening for the last two days.

l$.There are not enough employees to adequately care for the needs of residente.
16.The uncertainty and the failure to invoice and collect payments causes me and
my parents a great deal of stress.
2

 17.My

father,I

I

is scheduled to return to Allenwood after a hoepital

stay and he will require oxygen. I, and my mother, are concerned. about the

facility's ability to manage that with the uncertainly and staff insecurity.
18.My

mother,IF*""iJ'Jlt r", at Allenwood, but she is very anxious about

the uncertainty and is very concerned that she will be told she must vacant with
short notice.

Pillsbwv Manor South
19.My uncle,

I,I

ie a resident of Pillsbury Manor South, an assisted living

facility located at20 Harbor View Road, South Burlington, VT 05403. He lives in
Room

!

and has lived there since October of 20L7.

20.I am his Power of Attorney and manage his bills and paymente for his care.
21,His rent is approximately $5,700.00 per month and is supposed to be paiil
monthly.
22.The last invoice I received was in January of 2018.
23.The last time payment was processed wae in January of 2018.

24.In February of 2018, I submitted a payment and it was returned in May of 2018.
25,I epoke to the financial

officer,I

about my concerns.

26.There has been an increase in the staffturnover rate which makes

it difficult to

know who to tatk to about my uncle's care.

2T.Thestaffhave a diffrcult time inanaging his care, especially since his
Alzhei.mer's is getting worse and he has suffered delusional episodes,

3

 28.He hae fallen a couple of times and

I was not notified immediately. After one of

the falls it took the facility a day to notifu me, another time it was a few hours.
2g.My uncle has diabetee and I have asked staffto monitor his food intake, but they

still bring him deseerts that he is not permitted to have'
30.The uncertainty and the failure to invoice and collect payments causes me a lot
of stress.

31.I am so concerned that I have etarted to look

uncle'
DA?ED

/.\
* Q,i'JLl-A

,

Vermont, this

hr alternative placements for my

L

auy

rA

!

of I ln'awb*t,

2018.

STA,TE OF YERMONT

CHITTENDEN COUNTY,

At 6yer*

SS.

54h

personally
day of lJzr,'er"Lx"r. 2018,
upon her own
etatements,are
appeared and her acknowledged that the above
personal knowledge, information, and belief, and in so far as upon information and
she believes them to be true.

this

Public
My Commission Expires:

zll0tlg

4

 STATE OF VERMONT

SUPERIOR COURT
State of Vermont,
Commissioner of the
Departnent of Disabilities, Aging, and
Independent Living,

)

CryN DIVISION

)

DOCKET NO.

)
)
)
)
)

Plaintiff

)
)
)
)
)
)

v.

Homestpad at PillsburY;
Pillsbury Manor - South;
Allenwood at Pillsbury Manor,
Defendan'ts

)

AFFIDAVITOFI-L
The undersigned etates the following under oath and upon personal knowledge:

1. My nams

i*I

I

am over 18 years of age, -of sound mind, and

arn capable of making this afridavit. The facts stated in this affidavit are within

my personal knowledge.

2. I am 91 years old.
3. I reside

at Allenwood, a Pillsbury Senior Comrnunity, at 90 Allen Rd, $outh
have reeided at Allenwood since August L5, 2018, and

Burlingtan,

VI,

before then

I resided at Harborview. Harborview is an adjacent building

05403.

I

also part of the Pillsbury Senior Community. Combined,

thtee ydars in this senior community'

1

and ie

I have lived around

 4. I made the move to Allenwood because it provides

care not available at

Flarborview. Because of a decline in my health I use a walker and I need help

with bathing, laundry, and taking rnedications.

5. I should be paying rent, hut since March at 2A\8 neither }larborview

or

Allenwood have accepted payments. This situation is worrying me and most of
the other residents I oncounter.

6.

I've noticed changes since the rent stopped being collected. Many staff members
have left. Many people have quit including food servers, the man in charge of the

money, and the lady lhat clipped aur toenails. ?he hairdreseer quit for a while

but has come back. No one look care of the bushes and {lowers all summer long.

7.

On weekende we have buffets when we used to have table service. The weekend

buffets are only available from noon to 3 p.m.

8. I

hear people complaining about the changes to the food. They do not think

it

is

as good as it used to be. I am not too interested in food anymore so I have not
noticed as much as others.

9. I am losing

my vision and need to he administered eye drops 4 times a day. I

nerrer know what time a staff person
days when

will come by with my eye drops, There are

I get the eye drops three tirnes instead of four

10. Many peopie are concerned that the place will suddeuly shut down.

It is a topie

that comes up often at meals. We talked at today's meal (Saturday, November
3rd) about our concern

that we are all going to end up on the street. With

many peopie quitting people wonder whether the place will stay open,

2

so

 DATED

at@

vermont,

this{

day

af 'ilar,vnlgr, 2018.

J

By
STATE OF VERMONT
CHITTENDEN COUNTY, SS.
appeared and
are ma upon her own personal
far es upon information and belief, she
in
so
belief,
and
knowledge, information, and
believee them to be true.

Public
N
My Commission Expire*: 2ll0l19

3

 STATE OF VERMONT
SUPERIOR COURT

CIWL DIVISION

)
)
)

State of Vermont,
Cornmissioner of the
Departrnent of Disabilities, Aging, and
Independent Living,

DOCKET NO.

)
)
)

)
)
)
)
)

Plaintiff
v.

Homestead at Pillsbury;
Pillsbury Manor - South;
Allenwood ai Pillsbury Manor,
Defend.ants

)
)

)
)

ernru.qvttopl:expll
The undersigned states the following under oath and upon personal knowledge:

1. My name

I am over 18 years of age, of sound mind, and am

I

capable of making this declaration. The facts stated ifl this affidavit are within

my personal knowledge.

2. My name ir I

I

I

am over L8 years of age, of sound mind, and am

capable of making this declaration. The facts stated in this affidavit are within

my personal knowledge.

3. We are residents

of Allenwood, an independent living and resitlential facility

located at 90 AIIen Road, Souih Burlington, VT 05403. We have lived here since

May of 2018.

I

am in independent living and

J

is in assisted living.

4- We have not received an invoice since we have resided at Allenwood.

I

 5.

Because we have not received an invoice, we do not know the amount owed, but
we believe

it is approximately $7,100.00 per month total for both of us.

it should be paid to.

6.

We are not aware of when rent is due, how it is paid, or who

7.

No payments have been processed since we have resided at Allenwood.

8.

We have not had the opportunity to address this with anyone becauee the
employees do not know about the finances, One of the employee who seemed to
be aware of billing matters resigned last Wednesday, October 31st.

9.

We have long term care insurance through Metlife.

10.It is my understanding that the long-term care insurance carrier nceds invoices
to make payments
11.The uncertainty and the failure to invoice and collect payments causes us stress
and anxiety.

DATED

affpSzruup-ct{embnt, this Sday of
By:

DATED

day of

ermont,

2

2018

 STATE OF VERMONT
CHITTENDEN COUNTY, SS.

SjA

day of Nerl,rrber zor
peroonally appeared and they acknowledged that the above statements are made
upon their own personal knowledge, information, and beliet and in so far as upon
information and belief, they believe them to be true.

et 3. Er{.^n56r. ttris

Public
My Commission Expires:

zll0llg

3

 STATE OF \MRMONT
SUPERIOR COURT
WASHINGTON UNIT

)
)
)
)
)

State of Vermont,
Couimissioner of the
Department of Disabilities, Aging, and
Independent Living

CIYIL DIVISION
DOCKET NO.

)
)
)
)
)
)
)
)
)
)

Plaintiff
v.
Homestead at Pillsbury;
Pillsbury Manor - South;
Allenwood at Pilsbury Manor,
Defendants

AFFIDAVIT OF IT{ARY BOLTON

The undersigned etates the following under oath:

1. My name is Mary Bolton. I am over
capable of uaking this affidavit.

I

18 years of age, of sound mind, and am

am a nuree Burveyor with the Division of

Licensing and Protection in the Vermont Department for Disabilities, Aging &
Independent Living (the "Departmenf,').

2. My duties include making

eite visits to reeidential care honee licensed by the

Department for purposes of conducting investigations of complaints and facility
self-reports.

3.

On November 5, 2018, f went to Pillsbury Manor South in South Brirlington,

Vermont to assist with a follow-up investigation of variow complaints and

1

 report6 of regulatory violations at the facility. The allegatione included a report

that the facility was not paying ite vend.ors.

4. During

my investigation, I was told on Norrember 5, 2018 that the facility had

approximately 3 * 4 days of fooil reserves.

5. During

my investigation on November 6, the food service director at the faeility

told me that if they are unable to put in an order to Reinhart by November 7, the
facility will be "in trouble" in terms of food supply.

6. On November

5, a staff member at the facility also provided me with a copy af a

printout from the facility's computer syetem showing the current amount due to
Reinhart as of November 5. The printout shows amounts owed to Reinhart by
both Pillsbury Manor South and Allenwood at Pillsbury Manor, a neighboting

residential care home. Both facilities are owned and operated by the same
person or entitY.

7.

The printout indicates that Pillsbury Manor South currently owes Reinhart
g19,660.19. Allenwood at Pillsbury Manor owes Reinhart &33,774,75. Of this

combined $53,434.94 currently due, $1"9,888.64 is past due.

L

A copy of this printout is appended to this affidavit.

9. Pillsbury

Manor South has a eupply of "petty cash" ts use in emergency

situations.
10.

On November 6, 2018, I returned to Pillsbury Manor South to continue my
i:nvestigation. On this date, I learned that the faciliff only has $200left in its

2

 petty cash account.

Vermont,

DATED

this

6

drl.v ot

//tLt@r'/e:zou-.

STATE OF \rERMOhIT

CHITTENDEN COUI\IIY, S$.

ag-!r,rg!$hi, ft

day ofAhe^h{ s018,

f'n+% &tl{aqn#"nally

appeared and

ehe acknowledged that the above statements are made upon her own personal

knowledge, informatiou, and belief, and in so far as upon information dnd belie{ she
believee them to be true.

Notary Public

My Conmission Expires: ?lL0lLg

3

 ,..t

(htrprrft'nv. t,,cad.,"clcqn/hom.-?Jf,
I ,ttt.

tqt\.",

"Tll:f ""T*H'"lt";*

^

*r'rp

o ibrrnr.hml

?f,lftaaanl

lnventory

Rcclper

(PB-Rcculte,aapxl Repofta (httpa:tr,ilvwur.tresrdrrect.comrReporbarpx)

llon
C

usrguen lilFoRiilATjolt
Plllrbury filrnor Eouth

w

06403

BUR

.82268

+

Sor{li

NEW

ORDER Conbct Ntlltoner 30'116

Past Oua. 37.113.75
Currant Ousl $12,54{.44
Tolal Dua: 3r9.880.10
Tarms: 30 Dey
Hicte Dctalts

A

f8uR. a22t8t

Allennood

Soulh Eurllngton,

Vl

Pert Dss:
Ounanl Dua:

TolslDus:

IBUn:6e2561
Plllrbury Menor South

Curent Due:

Soulh Burlinglon, VT

Total Due:

Pest Dus:

$4772.80
02t,@t.gg

l3t

Tarms. 30 Dey

?74.75

t7Jr6.t5

tI2,W,U

frt g80.t3

Termsr 30 Day

)

 !,
Ita I
i
IN THE CHANCERY COURT FOR DAVIDSON COUNTY, TENNESSEE
NASHVILLE DIVISION
?SlSOCT 23 Pll h:

N}II.REIT OF AXEL, LLC,
,.:

l5

,, " "tt
f,l i
'' ' I :'i
, :i ;!
j;vii]'i.'r "'1
'"

"1"

Plaintitf

- -ile &il

v.

SH REGENCY LEASINC LLC, ANd
SH RECENCY MADISON LEASINO LLC,

N* - L"X :1*i:,3-r lJ

-"

Defcndants,

TENNESSED DEPARTMEN OF HEAI,T}I,
Party of Interest.

VERIFIED COMPLATNT
Plaintiff NI{I-I{EIT of Axel, LLC ("NI{I'}, fcr its Complaint against Defendanx SH
Regency Lcasing LLC ("Regency") zurd SH Regency Madison Leasing LLC ("SlI Madison"),
alleges as follows:

r.
t.
of

f'sltTllr$.,fljRlstltc'rjQs,a$lr_YEs_ug

NHI is n Delaware lirnited liability corupany registered to do business in the State

Tennessoc, having a prinoipal plaee

of business sl 722 Roberl Rose Drive,

Murfreesboro,

Tennessee 37129,

2..

Regency is a Dslaware lirnited liabilit.y company registered to do business .in the

Slatc of Tcnnessee, having a principal place of business at 14741 Dallas Parkway, Suite 650,
Dallas.'I'exas 75254,

484?-8? r l-12s6.6

 3.

SH Madison is a Delaware lirnited liability conpany registered to do business in

the State of Tennessee, having a pfincipal place of business

al

14241.

Dallas Parkway, Suite 650,

Dallas, Texas 75254.

4.

'fenn. Code Ann. $ 16'1 1-102, as
Jurisdiction over this rnatter is proper pursua$t to

circlit and chancery courts shae concurrent jurisclictior: over cases involving breaches of
'fhis
c6utr&cts, and because chancery courls have jurisdiction over cases of equitable natures,
Court has jurisdiction over Defendants as they are registered to elo liusiness in, lease property in,
and aperale an assisted care

5.

living facility in Madison, Tennessee.

Venue is proper as Defendants' contrastual breaches, t'orming the basis of this

Complairrt, concern a lease agreement (the "Master Leaset') and a sublease agreemeltl {tlte
.,Sublease,,) under which Regency and

SII Maclison failc<t to perform jn Madison, I)avidson

County, Tennessee. 'fenn. Clode Arur. $ l6'11-l15"

rI.
6.

IryrsqDUCTrqI{

This is an eviction action whereby landlard

Nlll

seeks to remove DefBndants from

NHI's properly after terminatioa of Defendants' contfactual rights to possess the praperly' NHI
Carler
entered the Master l,ease with Rcgency whereby Regency rvould cperate t]re Maybelle

Se'i.r Atlult Comnunity (,'Maybelle")

in Madison. T'ennessee. Rogency entered into the Sublease

'l'he Sublease inocrporated the terns of th9 Master
with its wholly-owneei sutrsidiary, SI-I Maciison.
to operate,Maybelle
Lease such that SH Maclison assumetl Regcrrcy's perfbmrance responsibilities
rmder the lvlaster Lease'

7.

After Regency clefaulted on the Masler l,e&so' nnd after NFII provided notjee of

the lvlaster Lease.
such defaults to Regency, Defendants have faited to onre the defaults under

[fn

gave notice of the
October 12,2018, as a result of Defendants' taih.rres to cttre these defuults, NHI

;ltl4l-8?13-1256.6

 tcrminationoftheMasterLeaseandSublease,effectiveasofOcrober23,20lS.
Leaseos and Suhlease's

DespitetheMaster

terninations, Defendants have fuiled to vacate Maybelle and abide by the

termination provisious requiring assistence with transition of operations of the faeility 10 &tsur€
the health and well-being of the residents.

NIII

seeks to have Deibndants rentoved from Maybelle

in a manner thal provides for lhe continued operation and tnainlcnance of Maybelle, including
appointment oi'a receiver over $H Madison to uansirion the license and operation of the f'ncility,
as required by the Master Lease snd $ublease upon a breach/de{bult, so thal the Ccurt's renredy

will

ensure the safety and care of the Maybelle

ITI.
A,

faciiity's residents.

FACTUAL BACKGROUND

NHI md Regency executt the Marter Leate, and Regency subleases to SH Madison.

8.

NI{l

cntered the Master Lease rvith Regency whcreby Regency would lcasc

property liorn NHI on which Regency would operate three assistori living, menibry care andlor
indepenclent living facilities prcviding scnior rcsidential accommodations, cne of those facililies

being \,Iaybellc. The Master l.ease is gltgghcd b*rctq as ll:xhihit

A. Although

NHI owns the

Maybelle pffperty, il cloes not posssris a license to operate thc Maybelle fac,ility, Rather, it granted
fhe righf to oi:tai:r. a license and operate the facility to SH Madison through alrengemenls within
the Master Lease and Sublease.

9"

The Master Lease contains sevcral covenants designed to ensure that the operator

olthe assistsd care living facitity has sul'ficient finaucial .sotvency. For e.xarnple, under
[.,ea.se,

the Mastel

Regency is responsib]e for a securil.y deposit ("seotuity Deposit"] in the amount of

$1,-560,000.00. Ex.

10.

A $ 4.4,

The Master Lease also requires Regency ta maintain a minimum "Lease Coverage

R&tio," definecl as "thc ratio of Net Operating Iucome for the applicable trailing tu,'elve (12) rnonth

period for the lfac.iliti(rs iu the eggregate, to the Base Reut for such trailing twelve (12) month
J
,i

34;"8? i l-

I

?

tl:

ir

 period."

lt

o'Lsasc
Covera.ge Ratic." Regency was required to "have a l.ease Coveragc
At1. I,

Ratio of no1 less than i,t)0 to l.00" for all of rhe Facilities frorn June 30,20i6 to June 30,2019,

!g! $ 11.3(ai. If the l-ease Coverage Ratio droppcd bclow the required 1.00:1.0i) ratio, Rcgency
was required to pay a "shortfbli Deposit" to NHI as tbllows:

"$lu{l!rL!-QEw.sit" shall mean, as of the date of oalculation, an
arnoun1 if positive, equal to (a) tlre product of {i) the Base Rent for
the trailing twelve (12) nronth period and (ii) the applicable Lease
Coverage Multiple for such period, minus ft) the sum of (i) Net
Operating Income for such trailing twelve (12) mnnth pericd and (ii)
any arnonnts previously funded as the $ho*fall Deposit and still
held by or on behalf of Landlnrd.
Id. Art. I, "siroltfall Dcposit."
I

1.

Additionally, llegency could request that NI{l fund improvernenls to the lbcilities

it lensed. l& $ 4.3. If NHI agreed to fund the improvernents, "[a]ny anlounts funded will become
pa11

of Lanellord's ldvestment." Id. Regency's Secruiry Deposit u,ould increase by an amount

proportion*l to the increase in Landlord's ltlvestmenf' Id. $ 4.4.

l?.

Section 22,2 ofthe Master l.ease lirrther requires that Regency provide NI{l with

certain inlormation, including:

a.

Each quar"ter

of tlre fiscal ysarl a completed

Con:lpliancc Certificste"), attached as Exhibit

ll

cerlificarc ("Quarterly

of the Masler Lease. cerlilying, among

other things, that Regency has not tlefaultcd under thc lviaster Lease and disclosing its
Lease Coverage Ratio (id, $ 2?'2(b));

b,

"[A]n itemized balance sheet and operating statenlenl for

each Faeiiity's

operations by nrcrnth anil year to date showing all revenues and operating cosls of the

Faoility"

{id

c,

{i 22.2(s});

A certificare ("Capital Expencliture Compliance Certificate") stating "(i) the

amount of Capital Expenditurcs macle et each Facility during the prir:r year, (ii) whether
4
48.1f-lt? I t-

ljtit.{,

 the Minimum Facility Capex Arnount was nret lbr the prior year, and

[iii) if

the Minirnum

Facility Capex Amouni has not been nret. stating the amount io be deposited into the
Escrow Accounf

d.

'(id, $ 22.2(d));

and

"Sush other informaiiau about Tenant Subtenant, Manager and its/their

operations at the Facilify as l,andlord , . . may roasonably request frorn lime lo lime,"
inclucling any pending regulatory actions which presently exist (id. $ 22.2(l)).

13,

Regeney's failure to comply with these obligations rvould coastitute default under

the Master Lease:

17.t !Xgu-lr!-ktbL[.
o'Evefit

events shali be deemecl an

Any atte rrr lnore of the following
of Default" hereunder:

{b) Tenant or Cuaraltor shall fail to observe or
;urlirrrll any o{ltcr tcrnt. r$r'cnnnt or conditirln of lhis l,cusc ot
Culrruly Rrrrl sur:lr lbihlre is ltol r:tttetl b,y'l'enanl itr (ittitt':ttttttr, as
th* r:rse nr*y l're, withir:r a p,"'rior"l ol tlrirty {'3(}) tlavs tfir:r Ntlice
thereof from l,andlord;"

& $ i7.l (ernphasis *dded),
14, NHI has the right to tsrminfit* the Mssler Lease "uptxr the occurrence and during
the continunnce of any Evenl of Default , . , upon ten (10) days' Notice of such termination," Id.

$ l?.2, Upon tem{natioa of the Masler Lease., Regency must:

transfer fo Landlord or
with Landlord or Lnndlord's
nominee in connecticn with the processing by Landlard or
Landlord's nominee cf any applications for) all Licenses then in
effect which relate to lhe operation of the Fucililies and.ior
cooperate with Landlord or its norninee in their efforts to secure
licenses for whicli Landlord or its nominee wishes to apply and
which may be requiretl by Landlord or l.arrdlord's nominee relating
. . . use reasonable gond laith efforts ir: (i)

Landlord's nominee {or

tr:r

r:.ooperate

to the ownership and operation of the l'-ncilities , .

td. $ ?5.1 I {ernphasis added}.

5
1843-81

t3.t2:{i i'

,

 15,

The Master Lease is to be govemed and construed in aecordance with the laws of

the S*rte of lennessee

(U

$ ?5.9), a:rd the prevailing parly bringing an action upon the Master

Lease is entitletl to resover its attomey's fees {id. $

t6,

25.l5).

The Master Lease authorized Regency to ertter into subleases with

designated entiti€s, inc.lucling its wholly-owned subsidiary, SH Madison. so long as such

a

{:e$ain

sublease

"rnemorializelcl] that the subterrant shall be fully liable for the perfonnance of all the obligations

of Tenant under the l,ease with respeel to such Property""

17.

I{

$ 21.4.

Accordingly, Regency entered thE Suhlease (sttachcd hcreto us lrlxhihif

ll)

wirh

SH Madison, which obligated SFI Madison to perform Regeuey's obligations rnder the Master
Lease:

4.1 . , , Ail of thc paragraphs of thc Master l,ease ate
incorporated into this Sublease as if fully set forth in this Sublease.
. Subtenant shall assurne and per{omt fcr t}re benefit of
Suhlsndlord and Master Landlord all of Sublandlord's obligations
under the Masler Leasc to ths exlent that such provisions ate
applicable to the Sublease Premises.
4.2 , .. Subtenant shall not do or pcrn:it to be done anything
which wculd constitute a violation or brcach of any rl1'the tenns,
conditions or provisions of the lvlaster l,ease . . . .

Ex.B$4.

B.

f)efendsnts hreaeh the Mnster Lease and Subleass.
I

L

iJecause the brcached provisions ol'the Masler tease. ancl additional provisions not

included in this Complaint, are designed to ensure lhat fhe operator af the assisted care living

facility has suflicient financial solvency,
irnpending inability

n breaclt

to pay debts and to

of those prr:visions is a strong indicator of

secure sufficient r€sourses

Regerrcy's and SFI Madison's breaches, detailed below, indicate such
pay dehts and to $eeul'e rssources to operate Mnybclle.

6

,t84?-liI1,i?anf,

an

to operat€ tlte facility.

ar irupending inatrility lo

 19.

For instance, afler SH Madison assumed operation of Mayhelle in accordance with

tlre Sublease, on or about September 2,2A16, NHI furrded Regency with $400,000 in Faciiity
Improvement Funds used to convert a portion of Maybelle from an assi.sted care living facility to
a memory oare

fncility. Under the Master Lease, NHI's provision of F'acility Improvement

required Regencyto increase its Securlty Deposit by

a

Funds

proponional amcunt. Because these Facility

Improvemepl Funds were used for Maybelle, the obligation to increase lhe Security Deposit fell
I

gpon

.QH

Madison as well, per lhe terms of the Sublease making Regency's obligntions under the

Nrlaster Leasc applicable to SH MadisBn tr: the extent that such provisions apply to

B. $ 4,2. NHIIs prcvision ol'Facility lrnprovement

},'unds required an increase

Maybelle, Ex.

of $9,333 in the

Sccurity Deposit.

20.

Despite SH Vladison's obligation to increase the Security Deposit by oniy $9,333.

it did got do so. SI.I Madisonos fbilure tr: increase the Security l)eposit by such a small amounl, ilt
comparisor"r with its other financial obligations under the Master Lease, undersoores its inrpending

inability to pay its debts and ro secure resources to operate Maybelle.

21.

Defenclants have also breached the h4aster Lease and Sublease in additional ways

in 2017, hrrther highlighting its impending insolvency and inability to rec.ruit resources to operate

llaybelle. For

example, Regency detivered to NHI Quarterly Cornpliance Cerlificates in August

2017,November 2tJl7,and Febnrary 2018 reporting Lease Coverage R.alios bclora,the required
t.00:1.00 ratio. 'I'huse Quarlerly Cornplianc') Certifioales are grtlachtrl -hg$l!!!

ttslhbil{{ (:.

Regency's Quarlerly Complia*ce Cerlificates forthese periods were .98 to 1,.93 to 1, and '83 to

l. respectively.

Regency paid the required Shortfatl Depo.sits in connection with lhe August 201 7

and Novembcr 20 t? Lease Coverage Ratios, Flowever, tbllowing delivery of the February 2018

7
4847'tt7ll-1256 6

 Quarterly Complianee Certificate, Regency tbiled to pay NHI the required Shortfall l)eposit in the
amoun! of $504,388.

22.

After receiving the Q.uarterly Cornpliance Certilicate from Regency in February

2018, XHI stoppcd receiving Quarterly Compliance Certificates altogether. Not only does the

failure to provide Quarierly Compliance Cerlificates breach section 22.2{b) of the Master Lease,
the failure tc maintaln the nrinimunr l,ease Coverage Ratio that would alsc be disclosed in the
Quarterly Ccmpliance Certifieate, and the failure to make a Shortfall Deposit to cure, constitutes
default uneler thc Master Lease. Ex. A $ 17.1.

23,

Becausc tho Quarterly Compliance Certiticates and Lease Covemge ltatio involve

Maybelle's linalsial obligations under the Master Lease and its compliance therervith, the failure
to provicle the Quarterly Compliance Certificates and to maintain the minimum Lease Ccverage
Ratio fell upon SH Madison us well, per ihe terms of the SubJease making Regency's obligations
under the Master l-easc applicabie to SF{ Madison ta t}re extcnt that such provisions apply to

Maytrellc. Ex.B$4.2.

24.

Dcspite Sl-I Madison's obligarion lo supply NHI with Quarterly Compliance

Certiticates and 1o rnaintnin a minimum Lease Coverage Ratio, it did not

25.

Thess and additional breachss were enurnerated

tler so,

in three letters frorn NHI

1o

Regency, including a June 7,2018 letter (the "June Notiuc l,etter"), enumerating lho$E bteaches,

for example, as follows:

a.

Failure to maintain the rninimurn Lease Coverage Ratio pursuant

1o

seciisn

I1.3 of the Masler Lease for rhe calendar year ending f)ecembcr 31,2017;

b.

Failure to incrEase tho Seculity Deposit by $9,333 as a result of NHI's

prcvision of Facility Improvement Funds untier section 4.4 of the Master Lease; and

I
,iq4l"!t?

I

3-

l:s,

fi

 o.

Failure to provide NIII with the required infbrmation under section 22.2 af

the Master Lease, including itemized monthly financial lnlbrrnation far the Facilities,

a

Quarrerly Compliance Certificate, proof that Maybelle has maintained its cu$ent assisted

living license, and a Capital Expenditure Compliance Ceriificale.
The June Notice I-etter is

26,
27

,

@.

To-date, SH Madison has not curetl ils breashes of the Master Lease.

On or about October 12, ?A18, NHI sent Regency notice of its intent to lenninale

tlre Master I-ease (the "Termination Letter"], effective

at l2Al

a.m. on October ?3, ?018. 'th{r

Tennirntion l,etier is attache-d hereto as Exhibif E. 'Iemination of the Master Lease also results
in tennination of the Sublease.

28.

Despite termination af the Master Lease

ald

Sublease, Defendanls have not vacated

Maybelle, nor have they assistod NHI with transitioning operators of the Maybelle facility in an
effort to maintain the health and rvell-being r:f Maybelle's reside'nts. Ex' A $ 25.1 I '

ry.

CAUSES

Or ACTION

COUNT I: BREACH ()F THn LEASE

Zg.

NHI repeats and realleges the allegations set fotllt in all previous paragraphs.

30,

Tlie Ma;ter Lease and $ublease are valid and enftrrceablc c'ontt:aets,

31.

SH Marlison assumed Regency's perfonnance responsibilities trnder the Master

Lease through the $uhlease.

32.

Dsf'endants breac.hccl tire Master Lease ancl Sublease by, at least, failing to:

n.

Maintain tlie rninimum Lease Coverage Ratio pursuant'to section

the Master Lease for the calendar year eri.ding Docember

9
4R4?-8',1r3-r256 6

31

1.1.3

,2017 through the plesent;

of

 b.

Increase the Security Deposit by $9,333 as a result of NHI's fund of Facility

lmprovemenl Funds under seclion 4,4 of the Master Lease; and

c.

Frovide NHI with the required information under seetion 22.? af tbe Master

Le&se, includiug itemized monthly financial information

for the Fasilities, a Quarlerly

Conrpiizurce Ceflificate, procf that Maybelle has maintained

its curent

assisted living

license, and a Capital Expcnditure Cornpliance Certificate,

33.

Defendants' breaches are material.

34,

L)efendants' breaches have c*used arrd

35,

Delbnclanls are liable to

will

NHI for their

continue to cause NHi danrage.

breaches

ol'the Master

Lease and the

Sublease.

36.

As a result, tlie Court should enter judgment againsi Defendants that they ;re liable

for their breaches of the Master Lease and Sublease.

COUNT

II: UNI,AWFUL DETAINER

37.

NFII repeats and realleges the allegations ssl farlh in all previous paragraphs.

38,

Defendants malerially breached the temrs of the Master Lease and Sublease.

39.

On or about Oclober 17,7018,

NHI gave nolice 0f its intent to lenninate the Master

Lease, ef.lbstive October 23, 2018.

40.

The Master Lease was termin*tecl on October 23, 2018.

41.

Despite the lvlaster Lcase's lermination on Octobu 23,2018. Ilefcndants have

remained in possession ol'the Maybelie plemises without assisting NFII in transitioning operators
of the facility lo protcut thc well-being olits residents.

47.

Defendants, having entered Maybelle as tenant and subtenant by contract, ate

tvillfully and without tbrce holding over the possession of Maybelle from landlord NHL

i0
4E4?-87

il-l]:6

6

 43,

Defendants' actions constitute unlawful detainer pursuant to'Ienn, Code Arur.

$

29-1 8-l 04.

44.

NHI respectftrlly requests that this Court issue to NHI

a

writ of possession evicting

Def€ndatrts from and dispossessing Deferrdnnts olthe Maybelle premises.

COUNT

lIIr REQUEST FOR APPOTNTMENT

OF

R3CEMR

45.

NHI repeats and realleges the allegations set forth in all previous paragraphs.

46,

Ternessee courls are vested with the power

safekeeping, collection, management. and disposition

to

o'for the
appoint receivers

of prcperty in litigation in

such. court,

whenever necessary to the ends of substantial justice," Tenn. Code Ann. $ 29-1-103.

4?,
103 residents.

Maybelle is an assisted care living facility praviding for thc care of approxirnately

SII Madisan

was to operate Maybeile pursuant to the terms of the Ma,ster L,ease

and Slblease. Howeve,r, Dclendants have defaulted an and rnaterially breached the Master tease

and Suhlease, resulting in NI{I's tennination of the h;faster Lease and Sublease. Beca*se the
Master Lease and Sublease ternrinalions were effective as of Octob er 23,2018, Defcndants ttuw

unluwfully detain possession of rhe Maybetlc prcmises'

4g.
a'd

NHi

Sublease, but

seeks evictibn

NIII

of Detbndants for their rnaterial

brea{.:hes

of the Master Lease

recognizes the continuing need to provide far the hcalth and safety of the

rcsidents living at the Maybelle

facility. Thercfore, NHI

seeks appointmenl of a receiver over

SI-L

Madisol that would conirol and clirsct an orderly tr*nsition of the licensc from SH Madison to a
temporary anrllor rrew operator. Appcrintrnent of a receiver under these circumstances is necessary
,,for the safekeeping, sollection, rrranagement, and disposition of propefty" and achieves "the ends

of substanrial.iustice." Tenn.

Code Ann.

$ 2g4-rc3. Artditianally, NIII

to provide auy rl€ces.sary funds ttl achieve such a stahle transitiol'

il
.lS4?-871 ',i. 125{r 6

stands ready and

willing

 49.

Therefore, NHI respectfully requests that this Court appoint

a

receiver to aid in the

transition of operators of the Maybelle facility.

50.

This is NHI's fust request for extraordinary relief.

WHEREFORE, NHI respectfully requests that the Court:

A. Enter Judgrnent against
B.

lssue to

Defendants for their ccrrtractual breachEs;

NHI a writ of possessiun evicting SH Madison fram and dispossessing

SH Madison of the Maybelle f"acility and propetty connected therewith;

C.

Enter an order appointing a rec.eiver over SH Madison that would control and

direct an orderly transilisn of the license frorn SH Madison to a temporary
and/or new operator-.with the close invclven:ent and approval of the licensing
agency, the Tennessee Depa:lrnenl

of Health-+o

assure the health snd well-

being of Maybelle 's residents pending completion of SH Madison's o,iction;

D.

Awarcl NHI its attorneys' fees pursuant to section 25.15 of the Master Lease
and costs incurred in this action; and

E,

Award NHI any and all oiher relief ta which it appears entitled.
Respectfully submitted,

BRapley ARnNr BolrLT C{.lMtvntrqls LLP

llv:
t{nwctl h. M,rrgau (Nc. 2021S)
Jason C. Palmer $Io. 361a6)
1600 Division Street, Suite 700
P.O, Box 34A025
Nashville, Tennessee 37203
Plrone: (615) 252-2311

Fax; i6l 5) 252-6311
rmorgan@hradley.conr
Att orneys fo r P I aint iff

L2
i,q4f -ltl i 1- 17-5ir ir

 VDRIFTCATION

l, rric.Mendelsohn

_-, being duly sworn, make oath that I hsve raad ths
foregoing Verlfied Complaint Seeking Appoiutment of Reoeiver and that the statements
containsd therein are true and couect to {re best of my knowledgc, information, ond belief.

NIII-REIT of Axel, LLC

,l

i

trt
ttl

$*u
Its:

sTA'm s;,

-J_t

11 1{.{r.tg1, I

{loIrNTy or, llvJ !:r.l***_, ;}

Sworn to and subsuibed before me, this

,)'-i'*day of October,20l8.

NOTARY

My Commission Expires:

X

-t7 -J,ct

?
!.,

pu8ti*

,t
t-"

13
4t4?.8? l3-1256.{

t"

l*l.-t--

'

,

 unlnu

vvwl

1O12t2018 7:31

FFLICIA

Darling Telle2lsrRrcr

CAUSA NO. DC-I8-07841

EAST LAKA CAPITAI, MANAGEMI:,N'T
LLC, SH REGENCY I,EASING LLC, ANd
NL }'W IN'I'ERMEDIARY I [,LC,
Plnintitfs,
Y.

NATIONAL TIEALTII INVESTORS, INC.
and NHI-REIT OF AXEL LLC'
Defendants.

$
$
$

IN

$
$
$
$
$
$
$
$
$

TTTE

DISTRICT COTJRT OI'

DAI,LAS C]O{JN'rY,',t'EXAS

95TII JUDICIAL DISTRICT

DEFENDANT AND COI]NTERCLAIMAN'I' NHI.RNIT OF AXBL LLC'S
EMERGENCY MOTION ITOII AI'POINTMENT OF RECEIVER T'OR
PI,AI]Y'I]IF}'S}I REGENCY LEASING, I,I,C AND EMERGENCY
AP3)LICATION T'OR TAMTORARY IN.IUNqTTVE RELIET
f)efendanl and Counterclaimant NI{I-REIT of Axel, LLC ("l,andlord" or "NI'II-REIT")

hereby tiles this Emergency Motion for Appoinlment of Receiver for Flaintifll
Leasing, l-l,C i"Regency

Sll

Regency

'l'enant") ancl Emergency Application for'l'emporary Injunctive ltelief,

and would respectfully show the Court the following:

I.

l"

ININONUC ION AND NEEN FOR tr]MI'R(}IINCY R&LIET.'

The Court must immediately appoint a receiver on an emergency basis for

i{egency Tenant and issue temporary injunctive to

(l)

stahilize Regency Tenanl's turbulent

business o;:erations; (2) avuid the suffering, bodily injury, of even death of hundreds of cldcrly

residents who are in jeopardy because

of Regency 'l'enant's actions; (3) avert its imminent

insolvency: 14) prevcnt fraud and protect property; (5) and prevent ineparablc harm lo l,andlord.

Z.

l,andlord owns three senicr housinglassislcd living lhcilities in lldianapolis,

o'Assisted Living
Indiana, Pineville, North Carolina, anil Madison. Tenncssee (collectively, the

Facilities"). Lancllord leased these facilities to Regency'Ienant pursuant to a June 30,2015 Lease
(the "l,case").

fr537433ti.6

[ix. Il.

PI
cLl

 3.

ltegency 'l'enant anri

its affiliates

operate the Assisted I.iving Facilities and

provicie care to apprnximat ely 2TAelderly residents (the "Rcsiclents"), T}ese Residents rely upon
Regency Tenant for various personal and healthcarc-rclatecl services, including. but not lirnited

to, the provision

o1.

health care and physical assisiance, administratiou of rnedicine, food and

nutrition, and ensuring the personal hygiene, safcty, and well-bcing of the Residents. lEx. A,
Declaration of Klisti Gaines at titl 5-6J,

4.

Regency Tenant is in severe financial and operational distress and.

if a teceiver is

not inrmediately appointed, thc health" satbty, and rvelfare of the Residenls will be placed in
firrther serious danger. T"he tbllowing developnents have occurred in the past several weeks, and
demonstrate tlre need for the Court to imrnediately appoinf a receiver;
Rcgency "l'enant fails to pay its vtndors, intluding fire alnrrn
services for thc Indiana facility

Sept, 13,2018

through
Present

bill for
fire alann services at the Indiana facility, causing the fire alann
Regency Tenant tbiled to timely pay vendors. irrcluding the
company to shut down the systern in violatiotr of Indiana law.

lEx. B, f)eclaration of Mary Walker *t !J 6; Ex. C, Declaration of

Tirnothy Sutton at 11 5; Ex. Gl,

Regency Tenant fnils to make payroll
pay
and
employees who care for the Residents

Sept.

ll, l0l8

Regency "l'enant fbiled
September I

l,

to timely make payroll as scheduled

on

2018. Regency Tenant made payroll the lbllowing day.

through

to timely make payroll as schedrtled on
Tenant ultimately paid all but fi:ur of its
Regency
?5,2018.
September
employees tliree days latsr on Friday, September 28,2018.
Regency Tenant again fails

Sept. 25,20lS

[Ex, B at !f 3; Ex. C at !l 3].

COUNTERCLAIMANT NHI-RNIT OF AXEL, LLCIS EMf,RGENCY MOTION
TO APPOINT Rf,CEIVER FOR PLAINTII"F'SH REGENCY LEASING, LLC
AND EMERCENCY APPI,ICATION FOR TEMPORARY INJLINCTIVE RELIEF

PAGE

2

 166-page report, Regency Tenant was cited for hundreds of
violations fronr the North Carolina Department of Health, These
violations rcferenced, among other things, dead cockroaches on the
floor, soiled and unwashed sheets and towels, ths smell of urine and
feces in the building, and lusing tra{rk of a resident with Alzheilnef's
disease who was found at a gas station a quader-mile away. lEx' D].
Local media cfews arrived at tlre North Carolina facility on September
lfi,?818 to report on these violations.

In a

As a result of these violations, the North Carolirra

Departrnent

of

Health and Human ServicEs downgraded Regeucy Tenant's license ta

a temporary

license that expires

in

Decernber 2018. [Ex. H].

This facility is also prohibited from accepting new patients'

bill for the Indiana
facitity. The electric conlpany threatened to cut nff porver t0 the
building, and the executive director af the facility nn'anged llof
Regency Tenant failed to timely pay the electric

residenis to evaouate the building on al1 emgrgercy basis (and partially
run the huilding off of backup generators) until the electric bill was
paid at the last nrinute. [Ex. A at !l!l 2l-?3; Ex. B af tl 9]'

5,

These disrurbing events follow more than

a year of financial instability and

uncertainty by Regency Tenant. As described below, Regency Tenant has failed to maintain the
required lease coverage ratio under the Lease since Augtst 2017. And, beginning in April 2018,
Regency Tenant's rent paymgnts under the Lease have been paid from bank accounts held in the

name

of other entities

associated

with Andrew White and East Lake Capital Managernent

(..East Lake.), not Regency Tenant or its wholly owned subsidiaries.

COUNTERCL.A,IMANT NIiI-REIT OF AXEL, LLC'S EMERGENCY MOTION
TO APPOINT RECEIVSR FOR PLAINTIFF SH REGENCY LEASING' LLC
AND EMERGENCY APPT,ICATION FOR TEMPORARY INJUNCTIVI RELIEF

PACE 3

 6.

In yet anolher instance of Regency T'enanl's bizarre, erralic, and unstable

behavior, at least two of the three execrrtive directors at lhe Assisted Living Facilities have been
instructed by represcntativcs
checks since

of East Lake not to

Februar! 2018. [Ex. B

at !f

l0;

cleposit tnore than $1.8

resident

Ex. C at u 9l. Andrew White has also threatened and

inrimidared at least one of the executive directors. [Ex. C at

7.

ntillion in

11 10.1.

These circumstanceso viewed together with the recenl disr.urbing svcnts at the

Assisted l-iving Facilities, reveal that Regency Tenant is in severe financial distress. This poses a
significant danger to the hea1lh, safely, and well-being r:f the Residents,

zrs

well as to Landlord as

the owner of these facilities. The Court must act immediately to prevent imminent bodily harm to
lhese vulnerable senior citizens who have been failed by Regency Tenant,

8.

Texas law provides the Court with the authority to appoint a receiver in the case

of arr entity's imminent insolvency or for equitable purposes to protect property and prevent
harm, Flere, a receiver rnust be appointed for Regency 'fenant to stabilize its business and
operalions, prctect propefty, ward

olf fraud, and avert

irreparable harm to L,andlord and the

elderly Residents who rely upon Regency'l'eaant ior nearly every aspect of their daily lives.

9.

Although NHI and l,andlord own the real estate and do not operate the Assisted

Living Facilitics, they are ready and willing to prnvide financial and material
Receiver 1o aid in the stabilization

ol

assi.stance

to thc

Regency 'l'enant's business and the proteetion of the

Resiclents. This inclutles provitling funding to ensure lhat payroll is me1, adequate stafling is

maintained, and the Residcnts have the focd, supplies, and medical care they need and deserve"

COUNTERCLAIMANT NHI-RBITOF AXEL, L[C'S trMtrRGENCY MOTION
TO APPOINTRECNIVER }'OR PLAINTIITFSH REGENCY I,trASING, LLC
AND EMERGENCY APPLICATION FOR TDMPORARY INJUNCTIVE REI,IRF

PAGE 4

 10.

Altematively, and in addition to the motion to appoint a receiver, Landlord asks

the Court for temporary injuncrive rclief conceming the disposiLion of the $1.8 million in
undeposited checks, as well as limits on Regency 'lenant's use oJ'ihose lirnds 1o ensurc the
protection of the Residents and the Assisted l,iving faciljties. This.injunctive relief is necessary

to maintain ilre status quo and avefl irreparable harm to the Itesidents and to Landlorrl.

IL
A.

Ancunanxl Ano AuruoRlrtus

The Court should immediately appoint a receivcr firr Regency Tenant to address its
imminent insolvencyo protect the health, safety, and welfare of the Residents, and
prevent harm to the Assisted Living Flcilities.
II

"

Landlard asks the Court to imrnediately appoint a receivet ibr Rcgency Tenant

'fexas Civil
undcr Chapter 11 of the 'I'exas Business Organizations Code, Chaptcr 64 of the

Praciise and llemedies Code, zurd the Court's inherent equitable powers. "'fbe clecision to
appoint a receiver is within the saund discretion of the tdal coun." Duvis v. Davis, 1996 WL
2(rQ935, at *2 ('Iex. App. --Dallas

l?.

Apr.

17^ 1996, no

writ).

lJy irs oun atJmission in this lawsuit, Ilegency I'enant is a l)elaware limited

liability conrpany with its principal place of

business

in Dallas, Texas. [Plaintiffs' Original

Petition at 1 ?]. Thus, this is the proper venue? and the Court has jurisdiction, tei appoint
receiver over Regency Tenant and irs propefly. 'fsX. Ctv. Pnnc, &

13"

Chapter 64 of the Jlexas

CnpE $ 64.071.

Civil Practicc and Rcrnedies Codc pcnaits the Court to

(l) "in an action between parlners

or

jointly owning or interested in any property or fund," or (2) "li)r a corporelion that

is

appoint a receiver in various circumstances, including:
others

Rr'.rV.

a

insolvcnt, is in imminent danger of insolveney, has been dissolved, or has forfeited its corporate

rights." Tex. CIv, Panc. &

Rptvt.

Conn $$ 64.001{a)(3), (5}.

COUNTERCLAIMANT NHI-RNI'T OF AXEL, LLC'S BMERGENCY MOTION
TO APPOINT Rf,CEIVER I.'OR PI"AINTIFF SH REGENCY LEASING' LLC
AND EMERGENCY APPLICATION }'OR TEMPORARY II\iJIJNCTIVE RELIEF

PAGS

5

 i.

RegencJt Tensnt is.fhcing imminent i,rsolvencY

14. A receiver for Rcgency 'fenanl is necessary beeause it is l'acing imminent
insolvency. .l'he l'exas Business and Commerce Code tlefincs "insolvency'o as

(A)

having

generally ceased to pay dsbts in the ordinary course ofbusiness olhcr than as a result ofa bona
fide dispute; (ll) being unable to pay debls as they becr:me due; or (C) being insolvent i'ithin the
rneaning of the federal bankruptcy

15.

law. TBx,Ilus. & Couu. Ccnn $ l.?01.

flere, Regency Tenant is imminently insolvent. ln the past sevsral weeks alone,

Regency Tenant has been unable to {1) make payroll anel pay its employees; (2} pay vendors who

provide necessary goods and services to the Assisted Living Facilities; and (3) pay the elcctric

bill for the Indiana facility. [Ex. A at litf l7-23;Ex. B at tlt] 3-9; Ex. C at $!] 3-7; Ex.

16.

.F,

Ex'

G"l.

Regency Tenant is also in default of the l.,ease with l,andlord because, among

olher reasons, it has failed to mairttain the required lease coverage ratio, which is an important

indicator of the financisl viability of an assisted living facility and Regency Tenant, lEx. A at
'T'his ratio measures the net operating income produced
!  71.

by a fhcility against the rental

payments due under the Lease. f/r/.]. Rcgency Tenant was required to mairrtain at least a
lease coverage ratio under the t,ease.
17

,

l:l

11d.. .

Regency 'l'enant reported lease coverage ratios below the requiretl

thc Lease in August 2017,Novemher 2017,

and February 2018"

lEx. A at tlll S-l

l:1 ratin under

11. Based on rhe

ratios reportect by Regency Tenant, Landlord estimates thal Regency 'tenant is running
$104,463 monthly nst cperating loss. fld. at

n i2l. Regency

a

Tenanl has lbiled to provide

L,andlord q'ith its most recent lease coverage ratios or financial statemsnts since February 2018.

pd.]. Accordingly, L,andlord is unable to determine Regency 'lenant's cuffent financial status,

COUNTERCLAIIUANT NHI-REIT OF AXEL, LI,C'S EMEI{GENCY MO'TION
'I-O APPOINT RNCEIVER FOR PLAINTIFF SH REGENCY LEASING, LT,c
AND EMERGENCY APPLICATION FOR TEMPORARY INJUNCTIVE RELIEF

PACE 6

 It is unlikely that Regency 'lenant's financial condition has improvsd, and, as shown by

recent

svcnls, likely has gottcn worse.

18.

Regency T'enan1 has alst'r ceased paying rent under the Lease lrom its own bank

account. From March 2018 thrnugh August 2018, Regency'l'enarrt's rent under thc Lease was

paid tiom the bank account of East Lake Capital Management, I.LC, [Ex.

A at $U 13-16],

Most recently, on Septcmber 6, 2018, Regency Tenant's reni was paid lrom an account held by
White Family, LLC, presumably associated with Andrew White.

19.
have resullcd

So great are Regency Tenant's insolvency and patienl care concems that th*y

in

substandard and unacceptable services provided

to the Rpsidents. 'l'his is

exemplified by an incriminating i66-page inspection rcport from thc North Carolina l)epartmenl

of l{calth. T'he report citcs Regency 'l cnant for hurrdreds of

violations, incluciing dead

cockraaches on the Iloor, live bedbugs, use of soiled and slained shests, and the smell of "uritte
and feccs" in the building. [Ex. D]. ln another instanoe, Regenoy'Ienant lost track of atesident

with Alzheimcr's discase who was later frlrnci al ft gas stalion a quafier-mile away. [Id.]. These

violations have caused Regency Tenant

to lose ils

pennanent .license, which has been

downgrailed to a temporary license that expires in December 2018. [h,x. H]'

2A. A tenant's lhilure to pay debts when due, combined

with the danger thal its

operations could be closed havc canstituted "imminent insolvencyo'and been a proper basis far

appointing a receiver over the tcnant's busincss. In Shn .4ngelo tlilton Uotet Co.

t.

B.b. Hail

Builrling Corp.,the court upheld the trial coufl's decision to appoint a receivcr over a tenant's
b,usiness at the request

of the iandlord. 60 S.W.?d 1049 (lcx. Civ. App. '- Austin 1933, no writ).

In tJrat case, the court found that the tenant was insolvent with evidence showing that, among
other things, the tenant "had ceased to pay its obligations in the regular course cf business,"
CO UNT IRCLA IMANT NH I-REI'I' O}' AXI L, I,I,C'S II M I]RG ENL' Y MOTION

.I'O

APPOTNT RECRIVER FOR PLAIN'TTFF'SH REGINCY LI]ASING, LLC
AND T]MERGENCY APPLICATION FOR TEMPORARY INJUNCT'IVE RELIEIT

PAGE

7

 "was mismanaging the property," and that the t€nant's business'owas in danger of being closcd,

which would greatly injure the property."'

Id.at

1052. 'lhese are the same circumstances

presented here. Accordingly, the Court should appoint

a

recr.:iver

over Regency 'fenant's

propcrty and operations because of its irnminent insolvency.

ii.
2L

4 resgiy t-is necesssry

to prQlect

the AsWryA tivins. Foci

Resident safety is. and should be, the first priority under ihese circumstances.

l{owever, another purpose to appoint a receiver is to prevent irreparahle harm to the Assisted
Living Facilities and protect the assets of Regency Tenarrt. The Courl rnay appoint
an action betwcen partners or others jointly interested in any properly or

& Rru. Cona

27.

a receiver

"in

fund." T'px. Ctv. Pnac.

$ 64.001(3).

Landlord holds an ownership interest in thc Assisted Living Facilities, rvhile

Regency'fenant has a leasehold interest undet the Lease. Landlonl also holds a security interest

in the

assets

of Regency Tenant. tlix. K]. Regency fenant's failure to pay

employees, pay

v$ndor$, and make necessary repairs, as well as its complete misrnanagement ol'the Assisted

Living Facilities has harmed, and will continue to harm, Landlord. ilrx. A all,231. For instance,
the North Carolina fiacility's future is in jeoparcly as a result of t]re hundreds of health codc
violations fcgnd there, which has also resulring in the facility's license being downgraded tc a
remporary license and barred by the state from aclmitting new patients. [Ex. Hl. Such gross
mismanagernent irreparably harms the value of Landlonl's propefiy, not to mention Landltlrd's
reputation.

23.

Similar lbilures to pay dehts and mismanagement of a business by a commercial

tenant has been found to be a basis fsr a receivership. See San Angelo Hilton Hotel Co.,
60 S.W.zd

at 1052. In thal case, the eourt found that "the appointment of a receiYer

COUNTERCLAMAN'r NHI-REIT OF AXf,L, LLC'S EMERGENCY MOTION
TO APPOINT RECBTVBR FOR PLAIN'I'IFf'SH REGENCY LEASING' LLC
AND EMERGENCY APPLICATION I'OR TEMPORARY INJUNCTIVE RELIEF

was

PAGE 8

 necessary to take charge of the property! including the leasehold, artd to contiuue operation of the

hotcl business in ordcr to protcct the property." Icl. The Court must appoint a rcceiver over
Regency Tenant to protect the Assisted Living Facilities.

Avoiding harm to the Assisted Living Facilities will also in tum protect the

24.

el{erly and vulnerable Residents who reside lhere. Unpaid employees, unpaid electrical bills,
unpaid vendors, a lack of funeling for repairs, and huncirods tlf healrh ijode violalions not only
harrn the Assisted Living Facilities lhemselves, but also endanger the Residents who rcly on
Regency'fenant lgr lbod, shelter, and critical services. Appointing a receiver is the only remecly
that can provide immediate protection for these elderly Residents.

B,

The Cuurt should appoint an equitablc receiver firr Regency Tenant to protect the
eldcrly Residents in the Assistecl l,iving Facilities and prevent mismanagcmcnt and
potential frsud by Regeney Tenant.

25. In the evcnt a receiver cannot be appointed undcr the othcr provisions of
Chapter 64, the Courl also has the authority undcr

nperations

to appoint a receil'er over the busincss

of Regency 'fenant under principles of equity. Chaptcr 11 oI' the Texas

Business

Organizations Code provides that thc Court "may appoint a rccciver for all of thc property, in
and outside this statc, of a foreign entity daing business in this state and its business

determines,

in

accorclaurcc

necessilate the appoiptment

the court

with lhe ordinat'y usages of equity, that circumstances exist that
of a receiver even if a receiver has not been appointed by

court." Tgx. Bus, ORc. Clonl:

$I

another

!.410(a). Similarly. Chapler 64 of the 'l'exas Civil Prac.tice and

Remedies Code permits the (lourt tc appoint a receiver

"in any other case in which a receivet

may be appointe<t under the rules of equity." TFX. L-lv. PR,qc. &

26.

if

RuH4.

Cooe $ 6a.001(a)(6).

Principles of equity necessitate the appoiniment of a receiver over the business

operations arul property

of

Regency Tenant for many

of the same reasons described above.

COUNTERCLAIMANT NHI-REIT OI" AXgl,, LLC'S IMDRGBNCY MOTION
T0 APPOINT RECEIVER FOR PLAINI'II.'FSH RnGENI:Y L0ASING, LLC
ANI' EMT]RGSNCY APPLICATION FOR TEMPORARY INJT'NC'TIVE REI,IEF

PAGE 9

 Itegency'l'enant is imninently

* if not actually *

insolvent and unable to timeiy pay its neuessary

oxpcnscs in the ordinary course of busincss. Executil,e dircctors from two of the Assistcd Living
'fenant being unable
Facilities have attesled to the problems they have experienced with Regency

to pay employees, pay vendors, pay the electrical bill, or pay for critical repairs. lFx. B, Ex. C.l.
Regency Tenant's gross mismanagement
hundreds

of the Assisted Living

of health code violations in North Carolina

Facilities

*

evidenced by

- also support.s an equitable receivership

over Regcncy Tcnant tr: stabilize operations and protect the Residcrrts of thesc facilities,

27,

A receiver is also

lllx, Dl.

necsssary to enswe that Regency 'l'enant and its owncrs do not

either mismanage or potentially engage in fraud rvith respect to fees received from l{esidents.
As dcscribed by the execuiive tlircctors of the Indiana and Norlh Carolina facilitics, East I.,akc
has instructed thenr not

lo deposit residcnt he checks in an amount of, collectively, more than

$1.8 million. Some of these checks date as far back as l"rebrr-rary 2018, many ol which may not be

able to be cashcd. 't'hcre is no rational basis for such instructions, parlicularly in light of the

finansial difficulties faced by f{egericy 'l"ertant. Landlord also holds a sec.urity interest in the
arsets of'Regency T*nanl, which includes thess residenl fees.

[ix. K]. A rccsiver nrust be

appointed to investigate this matter and take any and all measures to ensure that resident checks
are deposited and used appropriately ltrr the management and operations

ol the Assistet"l Living

Facilities and for the bcnefit of the Residents.

28.

' "'he

totatity of the circumstances here justified the appointment.of an equitable

'['he
health, safety,
receiver over the business operations, a$sels, ancl property of Regency 'l'enant.
and well-being o1'approximatcly 270 eldcrly Rcsidents depend on it.

COUN'I'ERCLATMA;\'I Ntll-Rf IT OI,' AXEL, [,LC'S f,MnRCENCY MO"TION
TO APPOINT RIICEMR FOR Pl,AIN]'IFp Sll REGENCY l,IlASlNG, Ll,C
AND EMI.RGENCY APPLICATION FOR TNMPORARY INJUNCTIVE RELIEF

PAGE IO

 C.

Proposed receiver, powcrst nnd pnymcnt of a bond'

29.

Landlord asks the Court to appoint the following receiver:

i.

Dawn Ragan
CR3 Partners
13355 Noel Road, Suite 310
Dallas,'Lexas 75244
(917) 376-2e81
dawn.ragan@cr3 Parters.coln

Ms. Ragal is a director wirh CR3 Partners, a national restntcturing, turnaround, and perionnance

improvement firm. She has previously acted as a Chapter I
healthcare inclustry, is qualified and capable

I

in

the

clescribed herein,

an<l

trusteeo has experience

of exercising the powers

'fexas law. Ttlx. Cltv. Pna.c'
meets thc legal qualifications for a receiver rmdcr

&

RrHa. Cooe

64.021. Ms, Ragan's profile with her education, qualifications, and representative experience is
attached hereto as Exhibit J.

30.

'l'he rsceiver appointed by the Court should be given all necessary powers to

ensure the health, safety, and welfare of the Residents, rnaintain, protect, and manage the assets,

propcrty, ancl operations of Regency'I'enant, anti operate the Assistcd l,iving Facilities pursuant

to the l,ease. Lantllord will presenl the Court with a proposed order at the hearing on this
Motion.

31.

Lagdlord is prepared to post a bond in an amount the Court considers necessary

'I'ex. Bus. Onc. Coori $ J L406(a){2); Tex. CIv. [)Rac.
and appropriare. S'ee

&

R-Er4-

Ooptl

$ 64.023.

32.

Landlord anct

willing to provide all

Ntll,

togcther, also represent to the Court that they are ready and

necessary financial support

to assist in the ffansitinn by the reoeiver'

COUNTERCLAIMANT NHI-REIT OF AXf,L, LLC'S EMERGENCY MOTION
TO APPOINT RECEIVER FOR PLAINTIFI'SH REGENCY LBASTNG' LLC
AND EMERCNNCY APPLICATIOI{ FOR TEMPORARY INJUNCTIVE RELIEF

PAGE

11

 including any amounts that may be needed up fronl to continue operations at the Assisted Living
Fauilitics,

33.

Landlord has provided notice to l{egency Tenant anil its counsel of this request

lor receivership. In light of thc

cxigenL circumstances ancl the inrminent threat

to the

lrealth,

safety, and well-being of the Residents, this motion is presented on an emergenoy basis and is

justified under Texas law.

D.

Application for temporary restraining ortler antl temporary injunction.

34.

Based on the evidence presenled herein, Landlord also asks the Court ftrr a

temporary restraining orrJcr and temporary injunction against Regency Tenant to avert immcdiate

and irreparablc harm to the health and safety of the Residents currently living in ihe facilities
operated by Regency Tenart, as well as immeeli*e and irreparable harm to Landlord and the

facilities it owns.

35,

The purpose ol'temporary injunctive reliel'is to ''prescrve the status quo of the

litigation's subject malter pcndiag a rrial on the merits." trwercontinentttl Terminals (o., LLC
Vopuk N. A. Inc.,354 S.W.3d 887,891 ('l'ex. App.-Houslon
1b obtain temporary injunctive relief,

i2)

a probablc

the interirn.

[lst Dist.] 2011, no pet.).

an appticant must show (l) a cause erf

action;

right to the relief sought, and (3) a probabie, imminent, and ineparable injury in

Id. All af these elcments

36.

v.

are mst here '

First, Landlord has assertcd counterclaims against Regency Tenant for breach of

contraut and declaratory relief arising out of md related to the l,ease. Thi.'l is the same Leasc that

govotls the parties' relationship rvith respect to the Assisted Living Facilities and relates to the
exigent circumstances presented here.

COUNTERCLAIMANT NHI-REIT OF AXEL, LLC'S EMERGENCY MOTION
TO APPOTNT RI.CtrMR FOR PLAINTTFF SH REGENCY LEASING' LLC
AND EMERGENCY APPLICATION FOR TEMPORARY INJUNCTIVE RELIEF

PAGE 12

 37.

Second, Landlord has

a

probable right

contended that Regency Teuant breached the Lease

in

to the relief

sought. Landlord has

several ways. The evidense presented

herein esrablishes that R"egency Tenant, by l'ailing to pay its employees, failing to pay its
vendors, and the adverse actions by North Cmolina Department of Flealth has breached, ar

will

imminently breach, at least the follo*'ing provisions of the Lease:

'

Section 8.3:

8.3

Conlinuols Operations. Tenant shall maintain continuous operatisns at
the Facilities is accotdflnce with the provisions of this Lease and shnll not sease such opentionq
ather than a tumporary cessation during any pericd of repair or reconsfuction required as s reeult
of darnage to or dertructio{ or Coodernnation of any of the Property, Teratrt shall npt
voluntarily reducs the nurnber pf units or close any Facilities without the prior wriften ccnscnt of
lxndlord.

:

Seclion 8.2:

t-?

Urcof lbe Farilititsandl-an4

Tenrm will bc recFofisible for mquiring st Tenanr's cslt snd
expgnse ffiy afl.d all Li*ens*s becr,tsirry frr itc rL"* and operaritn af the hapcrty during the Tryn,
snil $ill tiep anf rr.rionifl ifl frril fonx ord sffest $idt Licflts*.B {s rte, tifiil tims to time,
requirnd l'sr fie u*ec rondu*ted by Tq^ffit gn rht hogcttl, in an*ordlnce trift all L*g,al
R*-quircrrrens, rubjert to Sesion 9.!- Non*'idrslsfiding the limegoing afld olhtr'rtthnnc{6 u
opmating rhe Facilities in ccnnpliannc nith Legll Requiremenu ccntainsl in this L*asc,
lan4od acknorrledgse md agn$H fiaf *fific ,lrt certain oubtfiding Inatton rclated tD the

{a)

roning of the hrdianapolis, lndima Fa*ilitv, ther ttter tha Effective trlrc Te*:ant l+ill bc r*'aldng
g,i1h $ell3t lo rernhi rhe slfie and rhat r$ long ag Tenanr diligmtly canrinue! *uch cilbttt,
Tenant shall trfft bt dermnd to be tsilirg tD csmply u'ilh kt$4l &,equirernnurr hy reason of the
rximence of cush tfi.ttlst!.

(b)

Throughout thc entirc Terrn and subject t0 Tcnsnt's conteet right ar
shall use the Facilities solely iu accordaoce with its Peftnilted
Tenrni
sei forth in Article 13.
Usc{r) in ccrnplirncc with all rypticable Lngrl Rcquir€merts and dt other tcnnnr cov€nants.
prnvisious and confitions of thi* fea*e, subject ftr Section 9.2. Tenant rnay not ure the Fncilities
ibr n5y pufposc olhcr thrrr the Pcrmiltcd Uec without thc prior written conecnt of Landlord.
Tenant shall not commit or sufl'er to be committed any w&ste nor
shall Tenant eause or permit any nuisance on the Property.

{,:)

COUNTERCLAIMANT NHI-REIT OF AXEL, LLC'S EMERGENCY MOTION
TO APPOINT RECEIVER FOR PLAINTIFF SH REGENCY LEASING' LLC
ANTI EMERGENCY APPLICATION FOR TEMPORARY INJUNCTIVE RELIEF

PAGE 13

 [ix.

I at $$ 8.2, 8"3(a)-(c)].

38.
engaging

Landlord

wili suffer irreparable

'l'cnant is cnjoined lronr
harm unlcss Regcrrcy

in certain conduct that will harm the elderly

Resicients and

the Assisted Living

Facilities. Regency Tenant's conduct threatens the continued operations of the Assisted Living

'lhis
Faciliries, which in turn threatens the hcalth, safety, well-treing, and livcs of the Residents.

will

also result in irreparable harrn to Landlord and the valtte of the Assisted Living Facilities, to

say nothing of the damage to Landlord's rcputation, Although Landlord and its alfiliates do

no1

operate the I'acilitics, the ir econonric interests are directly tied to the reputation and aetions of the

operators, including Regency Tenant. Additionally, Landlord holds
assets

the

of Regency Tenant, which have been, and tvill continuc to be, harmed by thcsc aclions.

39.
callecl

a security interest in

Ni.II

Fgr instance, the daughter cf an clderly resident at thc Indiana facility recently

ancl

lefl a messagc expressing her concern about the facility's employees not bcing

paid and the risk to her father, fEx. Irl. In that messags. the resident statcd that, although
Landlord/l.Jltl does not operale the facility, "you are the {:r,vter, so I think ultimately yolr arc
responsible." {.t(t.1. This excmplilies the danger posed to the ll,esidents, the irrcparable ltarm to
Lan{lorcl's reputation, as well as the irreparable harm to the value of the Assisted L,iving
l':aci

lities themselves.

40.

Landlord

is

preparecl

to posi a hond in the

amount thc Court considers

appropriatc

41.

For these reasons, LancllortJ asks the Court tc) grant a temporary restraining arder

and, lhereaftsr, a temporary injunction pending the appointment of a receiver or trial on the

merits 6rclering ihat ltegency Tenant, ils orvners, members, employees, agents, and direct or
inclirect affiliates. as welI as any ancl all persons acting on their behait
COUNTERCLAIMANT NI.II-REIT OF AXEL, LLC'S EMARGENCY MOTIOI!
TO APPOINT RECEIVtrR FOR PLAINTIFF SH RNGENCV LEASING. LLC
AND EMDRGENCY APPI,ICATION FOR TI'MPORARY IN.IIJNC'I'IVE RELIEF

}AGE

14

 (1)

shall deposit and maintain all oulslanding checks, money crders, or other
payments from any and all Residents into a bank account held in the name
of SH Regency l.easing, LLC;

{2)

shall nCIt make any payments, tlistributions, withdrawals, monetary
transfers, or transfers of any property of inherent or monetary value
without the Court's express approval, other than paying ordinary wages
owed to employees ol the Assisrecl Living Facilities, paying vendors and
contractors reasonable and necessary to the operation of the Assisted
Living Facilities as any amounts become due in the ordinary course of
business, renl owed under the Lease, andlor any local, slate, or fedcral
t&xes currently owed by Regency "fenant; and

(3)

shall nst terminate any employees at the Assisted Living Facilities without
the Ccurt's express approval-

IIL

CoNcl,usltltrl

For the foregoing reasons, Landlord asks the Court to appoint a rscciver for Regency
Tenant, and

to grant l,andlord the temporary injunctive

requested herein, and

justly

relief- against Regency lenant as

fbr any and all other relief, in law or in equity. to which Landlord may be

entitled'
I{espectfuty submitted,
ls/ Dsniel D. McGuire
Daniel D. McCuire
State Bar No. 24081282
Michael M. Besser
State Bar No. 24010464

Poi.stnnllt PC
2950 N, Harwcod, Suite 2100
Dallas, Texas 75201
Telephone: (2 l4) 397-0030
Facsiruile: (214) 397-0033
dmcguire@pol sinelli.corn
mbesser@polsinelli.com
Courtse I .for DeJ'endants N at ia nal Healt h

Investors, Inc. and NI{ -REIT'o/ Axel, LLC

CoUNTERCLAIMANI' Nl{t-R}:tr OF AXE L, LLC'S EMERCENCY MOTI ON
TO AT}POINT RECEIVER FOR PLAINTIFF SH REGSNCY LEASING' I,LC
ANT' EMERGENCV APPLICATION FOR TEMPORARV INJUNC'TIVE REI,IEF

PAGE 15

 CERTIFICATE OF CONTERENCE
Given the emergency nature of the relief requested herein, I have been unable to confer
with opposing counsel regarding the rslief sought herein. Howevero I have provided opposing
counsel-notise that the movant will seek the relief sought herein from the Court at least lwo
hours in advance as required under the Dallas County Local Rules.
/sl Daniel D. McGuire
Daniel D. McGuire

CERTIFICATE Or SERYIqE
I hereby certifu that on October 2,2A18,a true and conect copy of the foregoing has been
served on the following counsel of record in accordance with Texas Rule of Civil Procedure
Rule 2la:
Eric W. Pinker
Sam Hardy
Patrick Disbennett
Lvur* Ptwren Cox & HuRsr, LLP
2100 Ross Avenue, Suite 2700
Dallas, Texas 75201
epinker@lyrurlip.com
shardy@lynnllp.com
pdisbennefi @lynnl lp,com
/s/ Daniel D. McGuire
Danisl D. McGuire

COUNTERCLAIMANT NHI-REIT OF AX[L, LLC'S EMERGENCY MOTTON
TO APPOINT RECEIVER FOR PLAINTIFT SH REGENCY LEASING, LLC
AND EMERGENCY APPLICATION F'OR TEMPORARY INruNCTIVf, RNLTEF"

PAGE 16

 EXHIBIT A

CAUSB NO. DC-I8-07841
EAST I,AKE CAPITAL MANAGEMENT
[,L,Cn SII REGDNCY LAASING L,LC, and
EL FW INTARMEDIARY I LLC,

Pluintffi,
v.

NATIONAL IIEALTH INVESTORS, INC.
and NIII-REIT OF AXEL LLC'

$
$
$
$
$
$
$
$
$
$

TN

DALLAS COUNTV, TAXAS

$
$

Defendants.

THE DISTRICT COURT OF

95TH JUDICIAL NISTRICT

Df,CI,ARATION OF KRISTI GAINNS
S.IATE OF. TEM.{HS

S F:h:

$
$

RUTIIERFORD COL'NTY

l,

$

"My name is Kristi Gaines. I am over

capable of making this declaration. 'fhe facts stated

18 years

of age, of sound mind, and am

in this declaration are within my

personal

knowledgc.

?,
heen employed

I am curently

employecl by National Health Investors, Inc. ("NI-II"), and

I

have

with NI'II since March 1998. My current title is Chief Credit Offrccr, and I have

held that title since February 2010. My responsibilities as Chief Credit OfficEr include, generally,

underwriting credit, as well as effectuating and finalizing due diligence and transaction
documents related to acquisitions, transactions, and dispositions by NI-II and its alfiliates"

3.

To fulfill these responsibilities. I have an understandin& of, and involvetnent with,

the business operations

af NHI and its

affiliates, inelucling NHI-REIT

of Axel, LLC

("NHI-RglToo or "Landlord*). Landlord is a wholly-onqled subsidiary of NHI.

65380446,1

PAGE 18

 4.

As part of my responsibilities as Clhief Credit Officer of M-lI, I am lamiliar with

thc operations of both

NIII and NHI-REIT, thcir rcal estate holdings,

and the June 30, 2015

Master Lease (the "l.ease") between Landlord and SH Regency Leasing, IJ.,(:
("Regency Tenant"), A true and $orrect copy ol'the Lease is attached to the Motion as Exhibit F.

5.

Landlord owns three senior housing/assisted living iacilities

hrdiana, Pineville, North Carolina, and Mariison,

'l'ennessee

in

Indianapolis,

(collectively, the "Assisted Living

Facilities"). Regency Tenant leases the Assisted Living Facilities from i-andlorct and is
rcspeinsible for operating the facilities. Employees

of Regency "l'enant who work at the

Assisted

I-iving Facilities provide a variety of services, inclucling, but nol limited to, providing health care
and physical assistance to rcsidents. administering medicine 1o residents, feeding residents, and
ensuring the hygiene and personal well-being of the residents.

6.

In total, the Assisted l,iving F'aeilities pn:vide scrviccs to

approxim ately 270

elderly residenls r,'ho rcly upon Regency Tenant for the services dcscribsd herein, and to help
them with their daily activities of life.

7.

Regency Tcnant has demonstrated sigls of financial clistress sirrce 2017 by virtue

of, among other things, its leasc coverage ratio. A leass coverage ratio is an irnportant indicator
of the financial viability of an assisted living facility ald its operator. The ratio measures the net
operating income prorlucerl by a facility against the rental payments due under the leasc'
ff.egency Tenant was required to mainlain at least a

L

i: I

lease covsrage

ratio rurder the [,gase.

In August 2017, Regency Tenant confirmed thal its lease coverage ratio for the

Assisted Living Facilities was below the ratio required under the L,ease.

9.

Regency "lenant again confirmed in November 2017 that its lease coverage ratio

was below the ratia required under the L,ease.

DECLARATION

OF'

KRISTI GAINES

PACE 2

6-531{0446.3

PAGE 19

 10.

Regency Tenant yet again conlirmed in February 2018 that its lease coverage

ratio was bclow the ralio requircd undcr the l-casc.

11.

Regency Tenant has failed

to provide

Landlord with its most recent lease

coverage ratios since February 2018.

12.

Rased on the lease coverag€ ratios rcported by Regency Tenant in August 2017,

November 2017, ancl February 2018,

it is estimatecl

that Regency Tenant is experiencing

a

$104,463 monthly net operating loss.

13.

In March 2018, Regeney Tenant's rent under the Lease was not paid from

an

accounl owned by SH Regency l-easing, LLC, but was instead paid from the bank account of
Easr Lake Capital Management, LLC ('"East Lake").

14.

East l,ake again paid Regency Tenant's rent urder the Lease in April, May, June,

July, and August 2018.

15,

Most recently, on September 6, ZAl8, Regeiicy 'lenant's rent under the Lease was

paiel freim an account associated with White lramily,

16.

LLC'

Importantly, all rents owed by Regency Tenant under the l.ease have not been

paid from a bank account it owns since March 2018.

17,

On September 26,2018, NIII received a communication from an ernployee at one

af the Assistsd Living Facilities who said that Regency 'l-enant (or one of its affiliates who
'lbese employees also informed
employs the employees) had not.made their most reeent payroll.

NHI they were aware that, or feared that, other employees at the Assisted Living Facilitics did
not intend to shorv up to work if they did not receive paynrent'

18.

Thus, if thc employees of'the Assisted Living F'acilities rcmain unpaid and do not

appear for work, their absence endangers the health, safety, well-being, and sven the lives of the

DECLARATION OF KRISTI GAINES

PAGI 3

65380446.3

PAGE 20

 elderly resiclents who rely upon Regency Teriant and its employees. l'his situation also tkeatens
the coutinued operation of the Assisted Living Facilities because each statc's licensing authority
rcquires certain staff,rng leveis to ensure proper care of the resident^s.

19.

NFII has received numerous other calls from ernplcyees at the Assisted Living

I;acilities, as well as family members of the residents who live there. Most recently, on
September 27,2018, NFII received a telephone voice message from Rachel tipman on behalf

of

her father, who is a residcnt and patient at the Indianapolis facility. A true and correct copy of the

email containing this voice message NI'II received, as well as a transcript of that message, is
attached to lhe Motion as Exhibit H'

20.
some, but not

On Septcmbcr 28, 2018, NHI learned that Regency'fenant had made payroil ibr

all. employees of the Assisted Living Facilities. "fo date, I am aware that at least

{bur employses wsre not faid on or about September 28, 2018'

21.

Also, on September 28, 2018, al approximately 10:15 a.m. Central, NI{l received

a call from Mary Watkins, the executive director of the facility in Indianapolis, Indiana, who
stated that Regency Tenant had not paitl the electricity
company told Ms. Watkins that thcy intended to shut

bill and as a result, the electricity

off power tn the building that

same day.

This wolftl require the evacuation of doeens of elderly residents to a differeni facility or
facilities. in addition to the disastrous impact on their ability to operate the f'acility. It would also
raise further concems for staft'regarding Regency Tenanl's financial situation.

22.

Ms. Watkins confirmsd to NHI that she had inlbrnred Andrew White

September 2&,2A18 of this issuc and fhe electric company's plan to turn

on

olf electricily to the

building later that day. Ms. Watkins reported that a small parlial payment had been made to the
electric company rnid-clay but the electric department adviseci her that thcy would still be cutling

DtrCLARA'I'ION OF KRISTI GAINES
65380446,3

PAGE 4
PAGE 21

 offthe electricity. Ms. Watkins then confirmed tn NHI that she informed Mr. White that

she was

preparing to evacuale the building.

23"

At approximately 2:00 p.m. Central, NI{I received anoths call from Ms" Watkins,

who stated thar Regency Tenant, or one of its affiliates, had paid the electricity bill at the very
last minute to avoid the electricity being tumed oflf. Ms. Watkins had prepared the staff and
residents tbr evacuation and was prepared to run the memory care unit

24.

Regency Tenanl's actions have caused, and

will

offof

generators.

continue to cause. irreparable

harm to Landlord. This harm takes the form of redueed value of &e property where the Assisted

Living Facilities are located and reputational damage to Landlord caused by Regency Tenant's
sonduct. T"lre economic damages that have been and

will continue to be sufTored by Landlord are

diffrcult, if not irnpossible, to calculate

ZS.

Most importantly to Landlord and NHI, Regency Tenant's actions present

a

serious risk of imrninent and irreparable harm to the residents of the Assisted Living Facilities to

the extent they ar.e unable to receive the physical und health-care related services and materials
they need.

lThe remainder ilf this page has been intentioanlly left blank.l

DECLARATION OF KRISTI GATNES
6J380446.3

PAGE 5
PAGE 22

 My date of birth ir Jlno t8. l9?1, and my
Mnr.ileesbom, TN 3?12*,

I

bu,riness *ddress

is 232 Rnhert Rose Drive,

declorc uldcr pcnalty of pcrjury thnt the infornrl*tior'r c{xltiliired

hcrein i* ltus *nd ecrrccl.
Exsc$tod in Rutherfbrd Cou*ry, Ststc

cf

Tenr)$$$ee, on

lltc

lil-

day of Oclohel 2018.

rri

^i. "'

Kristi

DECLARATION OF KRISTI GAINES

PAGE 6

65380446.3

PAGE 23

 EXHIBIT 

DECI,AIIATI0N$r MARY R WATKINS
STATE OF INDIANA

$
$

COUNTY OF BOONE

$

1.

My name is Mary R. Watkirrs, I{FA. I am over 18 years of age, of sotrnd mind, and

'Ihe facts stated in this declaration are within my persorral
am capable of making this declaration.
knuwledge.

Z. . I am cunently employecl by liast Lake Capital Managernent

("East Lake') and

I

(the "MorningSide
work at the Morningside of college Park, 8810 Colby Drive, Indianapolis, IN

Facility'). I have been employed there since
and

June 23,

2018. My curent title is Hxecutive lJireetor,

I have held that title slrce June 23, 2018. My responsibilities as Executive Directsr

inclu<le,

of the community for all facets of resident care, employees and

physical

general, oversight
envir$uneut.

3.
as

I ordinarily

r.eceive a gro.ss paycheck in the amount of $3,269,23 every two Weeks

compensatignfor my work, Payrull for nll employees was due

<in Tuesday, Septenrber

28,
and was substantially paid to all employees on Friday, Seplember

2018. Payroll

25,2A18

rryas also one

day late for the Prior PaY Period.

4,

In the event East Lake continues to not timely make payroll, I do not intend to

wages'
continue working at the MorningSide F'acility unless I timely reeeive my

5.
have

I am also por$onally

aware

of other einployees at the MorningSide Facility who

lell employmcnt or do not intend to continue working

at the MorningSide F'aeility unless they

Scptember 27,
timely reccivc their wages. Certain employees picketed in front of the building on

2018 creating more uncertainty for the care of our residents.

PAGE ?5

 6,

The facility is recbiving limited food, maintenance and paticut care supplies and

most vendor.s ars on a cashier check or credit card payment basis due

t'cr

lale payments. There ate

repairs needed to the facility to comply with licensing and safety staRdards that I

elo

not have the

ability to pay.
I made r.epeated attempts to contact East Lake staff and the awner of the company'

7.

Andrew Write, regarding these issues. My calls or emails have substantially gone u[answcred.
To date, I have no rgason to believe that these circumstances will improve.

g.

In my opinion, the f*ilure to timely pay ernployees and ne$essary vendors at the

MorningSitle F'acility puts the heaith, safsly, and well-being of ths residents at risk because thc
employees

will likely discontinue workirrg

there that provide irnportant personal antl health-cafe

related services to the residents that cannot be performed by the resiclents themsclves.

g.

On September 28, 20t8, the MorningSide Facility confirmed with the eleclric

company that eicctricity was to be cut off due to non-payment.

I

reachecl oul

to

F,ast Lake

made with lhe
managem6nt personnel and Andrew White regarding payment, Confirnation was

power company mitl-day that approximately $200 of an $S,180.17 balance was paid and were

fi'ther
ancl

advised that power was still scheduled to be tvrned

Andrew White via email and advised wc

vuere

off. I agnin reached

out to East Lake

pleparing to evacuate the building to another

location. Hourly calls were made to the elechic company

a$ wE prepared to

evacuate. At 3:00

caused mueh
BST, w(, sonlimed with the electric company thnt fult payment was made' This
unrest to oru employees (on top of the payrali delays) and residents.

10.

for
Clurrently I have in my posscssiou, approximately $845,000' These ate checks

2018 nnd prior to my
resident monthJy fees forpayment of selices since approximately February

mffi16

 cmployrrent I

unas ins1arctsd

these cheok$ rmtil

by Ben Lorril, East Lalce Vise Ptosident, Underwriting to hotd onto

frr&et insructed.

[The remdudcr of &ls pago hm been lnt*nliondly left btank

l

N,}Rfrry

 My namc is

k 0t//-/f6/

ls

under penalty

-, and my nditresr

of periurY that the

inforrnation containedherpin is truo anrl corrcct

Executed in

8-*e

Corrnty, Staft

of

,Jnd***-

on the

"?.8

*

day of $optember,2018.

//Fe
$ignature

T'AGE4

PAGE 28

 EXHIBIT 

FnC  {nA:r'I(rN or' "rn{ornY $ul"r'$ii

CAROLINA

t

corrNrY of MECKLEXBTJRO

I

s'rA'l'H {}F NOR'I'H

1"
caBable

My name is lim*thy Sunon. I am over l8 years of age, of sound rnind. and am

of making rhis declarstian" 1}r laets srated in this declaration

are within rny persanal

knowledge.

?.

I arn cunently emplgyeil by bast l-ake Capital Managernenl ("Eest

l",alce") and

i

work ar the Regency ar Pineville Faciliry {the "Regeacy Facility"}. I have been enrplol'ed there
since October 31.2{)17.

My current title is Executive Director. and I have held that title

March 2018. My respansibiliries as Executive Direcror include, general. oversight

since

uf the

community for all f'acets ot'resident care. cmployces and physical environment'
s.s

.

I crdinarily receive a gross paycheck in the amount of $3,269,24 evcry tw$ wecks

25' zfi.'8
compen$align I'or my work. Payroll for all employ'ees wa$ due on T'uexlay" Septemtrer

and was

subst$tially paid rr: all ernploye€s on Friday. Septernber 28. ?018' Payn:ll was atso one

day late for the Prior PaY Period,

4.

ln the event East Lake continue$ t.) not titxely makr pal'rall, I do nol intend lcl

continue wrtrking at the Regency Facility unless I timely receive my *'age$'

S.
vendors are $:l

'lhe faciliry is receiving limited maintenan{:e Bnd patient care supplies and most
a

*xhier check

ur cretlit card payment hasis tlue to late pay'ments.

ltrert

are repairs

to pay.
nscded io the facility rr, comply with licensing standards that I do not have the abiliry

6.

I made repeated aftempts to eontact East Lake staff and thc owner of tlre c$mpafly'

gone unanswersil'
Anclrew rffhite, regarding these issues. Mv calls or cmails have substantially

-lo

date, I h*ve no rea$on to believe that these circumsta$$es

will

im5nove"

PAGE 30

 7.

ln nry opinion,

tlx

failurc to timely pny employccs md nsccsstry vcndon rt thc

Regency Facility puts thc heatth, safety, and wcll-bcing

of thc residenb al rirh

bccauro

thl

omployecr will likoly dirsontinsc workiry therc rhat provide irnporail pcrsonal rnd hcalth+rrc
rslated services ro the resldents that cannot be performed by the residents themsclves.

L

On September 26,2018, I personally obscrved local news medis pre*nl at &e

Regency Facility to cover the risk$ presented to the residents of the facility during a recent Sutc
inrpection,

9,

Currontly

tbr rEsident monthly

I hav* in my porrc*sion, appmximatcly S1,000,000. Tlrclc rrc chpch;

f-ees

for payment of services since approxirnately Febru*ry 2018. I was

inrtructod by Eut Lakc to hsld onto thesc ehe$kr wrtil finther instructrd.

10.

Furthsr,

I

havc pcrsonally bern altacked, thr€stsned and verbdly abuscd by Mr.

White.

lTtr rcndrdrof thb prlp hrr bcor hicnthrrlb bfl bhrLf

pa{iE

t

PAGE 31

 My nunc

is

5

h

My dals of birfh is

tSlLFn*€.il t!.,,'e 6Ll.&c"24l

f

f*oa:.,uFsft . urd my addrcss

dcclsrc undff ponalty of pcrjury thrt ttrc

ioformatisn oont itpd hcnln ic tnrc rnd conpcr

Exccuild in

dr&rt"f . County, gtate of il,p.tl &oty$-, on thc Afuh

day of Soptanbu,2011.

FAGNT
FAGE 32

 EXHIBIT 

HEALTH CARE CENTER VIOLATIONS : HCAIth
inspectors report hundreds of violations at south
Charlotte Alzheimer's care center
Illaine Tolison

CHARLOT:1E, N.C, - Health inspectors found a south Charlotte Alzheirner's care center in horrific
eondition, a repoft reveals.
The repo* says patients are being bitten by !ug., cockroaches were found on the floor anel workers
failed io notice when a patient in a wheelchair made it outside and into traffic.
Channel 9 reporter Blaine Tolison investigated the t66-pag_e statement of de{iciencies from the state
clirected at Rbgency Retirement Village on South Boulevard.

flontent Coutinues Belcw
Mia Guinther, who took her father, a retired Army veteran, out of the care center in Jalluary, sairi
she isn't surprised by the long list of violations'

"It was not what it rvas meant to be," Guinther said'
Guintler said the staff members at Regency weren't ordering her father's heart medicine that he
depended on since his stroke.
She also wasn't happy

with the conditions.

"The front room look clean nice, neat, rvelcoming," Guinther saicl' "You go up to the second, third
floor, it just smells wretched.'

When Mecklenburg County health inspectors visited Regency earlier this month, they found dead
cocl<roaches in several areas of the builcling and live bedbugs in a room'
In two other rooms, they found soiled and stained sheets.
Inspectors also took off points for a list of repairs and cleaning that are needed'

Guinther saicl she brought up some of the issues to management.

"I said it smells real ba{," Cuinter said. "He said, 'These people are bed-bound. What do you want
me to do about it?"'
The state inrestigation found more violations.
One resident had a cat that would get loose and bite staffers if they attempted to catch it.

Investigators smelied urine and feces in the building, along with disrepair and disgusting
contlitions.
PAGE 34

 In December, a patient with Alzheimer's disease Ieft the facility in his wheelchair when the front
d.esk attendant *as on a smoke break, and made it to a gas station a quafter-mile away.
"He knew something was wrong there. He wanted out of there," Guinther said'
Regency has a provisional license to operate until December.

"Really start researching your places," Guinther said.

Read more top trending stories on wsoetv.€omi

. 'I eouldn't seg him an)fwherc'; Father of niq
. Fire ants attack. nearly kill NC woman
r

.

'

tgsons charged with biqamy
Wednesday
ioreeag!-cutlsakwAtCH: John Ahrens'
$peed believed to be a factor incrash t

Ad-elptive trrotber of Eriea

O zorS Cox Media Group.

PAGE 35

 Mary Watkins
From:
Sent:
To:

Suhfnct:

Benjamin Lord
Tuesday, September 11, 2018 11:?6 AM
Andrew White; Chelsea Balestra
Update Regarding Payroll

Team,

We are sorry for the delayed communication regardlng payroll. There were certain issues with the payroll processed
two weeks aBo. Working with Paycor to resolve those issues this pay period created certain issues with the timely
processlng of payroll and the tirnely initiatlon of UPS deliveries. lt is gur understanding that propettles in Vermont have
received their checks and direct deposits. lt is our understanding that the balance of the portfollo will receive direct
deposit today and rheck delivery tomorrow. Of course, this is our fourth issue with Paycor's tlmely delivery in the past
three rnonthr and we are currently to evaluate other alternatives to avold further issue in the future.
To the extent that any of you have nst recelved dlrect deposit by this evenlng, please advise immedlately, Also, please
share the substance of this message with allaffected employees.

8en lord
East lake Capital Management
1920 McKinney Avenue, Sulte 700
0allas, TX 75201

blord@elcm,com
Cell: 602-989-0652

SEostLoke

1

FAGE 208

 Mary Watkins
From;
Scnt:
To:

Subfcct:

Mary Watkins
Monday, September 17,2A1E 4:09 PM
Andrew White; Sarah Moreau; Chelsea Balestra; Benjamin Lord
lndiana Department of Labor

We have had a very eventful last week with the events of
employees not getting paid. The Indianapolis police was on property with 3 nowpa$t ernployee to pick up her
police
chect," Wo explainejriratthere was a mix up in payroll and *s were wo*ing ongetting it fixed. The
left and let thagirl know that she has to allow un a gracs period to fix payrnll erors,
The person has-now oalled the Indinna Departrnent of Labor wtrich has left a message for me to call them to
1.*"fr'u,r.rolutior- His name is Steveo Indiana Department of Labor, 31?-808-7916. Please advise how you
would like rne to proceed. Thank ycu, Mary Watkins-Momingside of College Park.

Hi

All,

Sent fi'om nty Samsung Calaxy sntartphone.

l.

PAGE 207

 Watkins

Ma

Mary Watkins

From:
Sent:

Tuesday, September 18, 2018 2:09 FM
Benjarnin Lord
Andrew White; Sarah Moreau; Chelsea Balestra
Re: Vendor Payments

lo:
Cc:

Subjett:

Hi Ben. I have vcrified that all the invoices we have were sent as attachnents with a delivery notification 1?rr
eash email. l-Igw far would you like me to go baslc and I can rc-send thern to you? Mary has been irr the
hospital and caught it all up yester.clay" We-were working tcward getting it all reconciled but. we have only
t-"Jin.O notificaiiql that US Foods had becn paid in the last 3 weeks and now tbe AT&T bill tbday. Do you
payroll, It has
lrave an updated paid file io share?? Also we itill have people that have not been paid finm last
I
still have not
with
us'
been a Aaity issue that has been a reason fior a couple ernployees lo leave emplornent
Elurn
rcturned the call to Steve at the Indiana Depaltnrent of Labor because I have reeieved no oontact {i'orn
reganling that malter. Do you have an update on that stattrs as well?
- I also had a family ***b*r say they were going to file a complaint wilh the State for not cashing their
legal
oheoks and causing unn**rurory strcss on their:parents. Another resident is voicing they are seeking
consult nn their slatus ancl payrnent obligationsPlcasc advise.
Thanlc you,

Maly Watkins

ScuI

fioll triy Sanrsttng Calnx.\'

stltattpltotls,

Origirral message
From: Beni arnin Lord <blord@)elcrl'com>
Date: 9118118 l2;09 PM (GMT-05:00)
"f o : M aty Watk i ns <mwalkins@nhsen iorl i v i ng' corn>
Cc: Chelsea Balestra <cbalestra@elcnt'com>
Subjectl Vendor Payments

Hi Mary"

A few thirrgs:

.
.
.

AT&T Bill

has been paid, servise should be restorcd imnrinently

On all future emails r:egarding ilaily updates & vendor paytnents, you can send them to
anyrnor€.
A.11 1!;r:J.111,1i!lr,rr. No need to send to me, Andrew ol sarah individually
have been included in the daily
ilrvoices
no
actual
littls
1o
that
I'm
seeing
pnymcnts,
n"gutUing u"o,lo,
'upJates
we need them to make a dent
people?
If
not,
ta
other
fr, **urrrf weeks. Were they maybe sent

PAGE 208

 inthevendonpaymente, Itwouldbebesttostartwlththehighestprioritypayncr$swcnesdtomaks
loday.

I;Iappy to dissnss ifyouhave any Elestions.

Bon Lord

East LakE Cap&al

\Ianagqnent

1920 McKhncy Avenue, Suits 700

Dallds, TX ?520t

blordtdslcm.cnm

Cell:602-9 8g.o6sz

#EostLoke
gatrltdI tlaae$orrrtrl

2

PAGE 2Og

 MaryWctklne
From;
Sontl

MaryWatkins

To:

Andrsw White; Benjamin l.ord
Ombudsmen nesds immediate atientionl
ombudsmanjpg

SubJect;

Attachmentr:

Friday, September

2t, 2018 2:53

PM

HlAndrewand 8en,

not been
Attached'n a note I recelved from the Ombudsman today. Someone reported that thelr checks have
the State about this
cashed and they have not had any bllllng since February. The Ombudsruan wllt most likely contact
matter,
I have not contacted herYet.
Please advlse,

Thank you,

Mary Watklns, HFA

1

PAGE 2,IO

 Mary Wetklns
From:
Seht:
To:
Subfcct:

MaryWatkins
MondaY, SePtember 24,201811:57 AM

,{ndiewWhite
Ru regencY PaYroll

Good Morning Andrew,
please call me regarding the ornbudsman

visit. Thank you, Maty

Sent fronr my Samsung Galaxy smarphone.

Original mes$age
From: Andrtw Whire <awtrite@elcm.com)
Date:9f24/18 10:27 AM (GMT-05:00)

i":

f"f""ti", Eidr;o.*.ia*n6*seniorliving,oofr),

Mary Watkins <mwatkins@nhseniorliving.com>, Scott

$utton <ssutton@nhsenioiliving.Gotll)
Subj ect regonoy PaYroll
Montine, Mary & Scott,
rather than Tuesday. we are
with each of the last several week$, paychecks wlll be received on wednesday
to
occur.
continuing to look into alternatives to Paycor such that this does not contlnue
As

Andrew

Andrew White
East Lake CaPital Management
ur!t*"9-9i rlU ;1,{ s' il
M: +1.917.825.1308

:

I

PAGE 2T1

 Marv Watklns
MaryWatkins

Frsm:
Ssnt:
To:

tueiday, September 25, 2018 4:23

PM

Cc:

Andrew White; EenJamin Lord
Chelsea Balestra

Subfect:

FW: Ombudsmen needs immediate attentionl

Hi Andrew and Ben,
sorneone to
We have had events the last couple of weeks of which I have sent emails to you. I am asklng for
Green,
Marcia
Ombudsman,
The
Labor.
of
Department
respond direcgy to the Ombudsrnan and The tndiana State
not
checks
the
Residents
wlth
called agaln toiay and left a message that she wants a plan of action for the situatlon
a calltoday. Also
being calhed and not being biiled since rebruary. Her number lslLT-829-1078 and she is expectlng
paid. our
Steve from the lndiana Delartment of Labor was here in person today about employees not being
from Corporate
anyone
frorn
paid.
heard
get
He
has
not
going
to
explanation was a payroll issue and everyone was

offlcer. His number

ls 317-808-791S'

gettlng paid till
We are having employees quit. Two walked off today when they found out they were not
tomorrow because they have autornatlc drafts set up.
Please let me know as these lndiana agencles have

to be called.

Thanks,

Mary

From: Mary Watklns
Sent: Friday, September 7L,2OL8 2:53 PM
To: Andrew White <awhite@elcrn,com>; Benja min lord <blord@elcrn'com>
Subie*l ombudsmen needs immediate attentionl

Hi Andrew and Ben,

been
Attached ls a note I recelved from the Ombudsman today, Someone reported thst their checks have not
this
State
about
the
contact
cashed and they have not had any bitling slnce February. The Ombudsrnan wlll rnost llkely
matter.
I have not contacted her Yet.
Please advise.

Thank you,

Mary Watklns, HFA

1

PAGE 212

 Mary Watkins
Frort:
Sent:

To:
Subfect:

Communications

Thursday, September 27, 201 I 12:09 PM
Communications
Furr 79083 payrolls check date 9n8118

Folks,

from paycor. We wilt now be able to re-process today direct deposit and check
dellvery tomoffow.

See below update

From: Aya Patterson <apatterson@paycor-com>
Sent; Thursdan September27,2018 10:44 AM
Tor Com rnunications <cornmunications@elcm-corn>
SubJech ?9083 payrolls dreck dateQ ZS LS

We have rolled back all the payrolls originally submltted on 9/25/LSwlth a check date of 9/26/18 back over
your slde. at this time, you will look through each of the paygroups and resubmit these payrolls over to
us. Once all have processed, we will send you the wlre request as usual.

I

PAGE 213

to

 Home Company Enrplayees Reporling Me Rescurces

curonfiy logqed ln io 79083 - Eml Lahs Capftal tlanaqcmant Employsr I LLC

You are

i- l'arr4e t 't'rir ;

Client

Psyruoi

-'

Curan!

'

lmplementation

1

Payroll

79093 - Easl Lalro Capltal MsnsgefisnN Empl. .

r

Peylnll

Payroll

Paygroup

r

Pfryroll

HarmEn

I

Pitvtcll

Paygisup

Payrcll

OFlahomr city

Paygroup

t

Payrctl

Charlotta

t

'

Payroli

Paygro*p

I

.

Payrsll

Corpontt

{

,, Payroll

Paygroup

t

, Payroll

lndltnapolls

{

Pfiyr0lt

Faygrflilp

f

Payrcll

Midlson

(

, Payroll

i

Please

let me know if you have any questlons,

Thank you.

fgglrrsdrJe Plggsg be-gg.tg-!X!lgds.S,{$r glie{rt E-:t{*f&eff

iv.vq-ryr s.Iz1E;1I

Aya Patterson   $enior Business Supporl I Paycor
Phone: t-855-565-3285 Ext 20175   Fax 913-262-3889
gggttelson

@

gql&Llgn

I

uo:.v.w -8

a&{'au

8050 Marshall Drive. Ste {
CST TJI*F
SamCST

*

dfur
Thls message, including any attachments, may contaln lnformation which is confidentlal and privileged. Unless
PAGE 214
2

 EXHIBIT 

Watkins
Fromr

Srnt:
To:
SubJoct:

Mary Watkins
Thursday, September 13, 2018 11:58 AM
Andrew White; Benjamln Lord; Sarah Moreau; Chelsea Balestra

Att Blll

problem, Then we
Our fire alarm system is down. We called the company to veri$ it was a connection
for non
ouit*O ATT and they verified that the phone necessary for the alarm has been disconnected
1 743.
paynent. Our account # is 31787 6zztircgq-2. The nqmber to make p. ayment over the phone is 800-924-

Hi,

State Offisr
This will ne€d to be paid immediatoly as the Indiana Regulations requite ii tc be reported to the
within 4 hogrs of bsing offdue to {ire hazard afd resident safety
Please advise as soon as Possible'

Thankyou, Mary

Sent

fton my Samsung Calnxy

smatqtbone.

PAGE 216

 Mary Watkins
From:
Sent:
To:

Mary Watkins
Friday, September 14 2018 9:25 AM
Chelsea Balestra; Benjamin Lord; Sarah Moreau

Cc:

AndrewWhite

Subfect:

ATT and payroll

Good Morning All,
May I get a confirmagon coda that the ATT for the fire alarm has been pald? we tried to teset lt and it would
not reset so we need to know what you would like us to do ln thls sltuation.

.

pay. We have had two
Also, the people that were not pald are gettlng furious that they have not received thelr
people qult because of it. Please advise what you would like for me to tellthem'
Thank you,

Mary Watklns, HfA
Morningside of College Park

1

PAGE 217

 Mary Watkins
From:

Mary Watkins

9ent:

Tuesday, September 18, 2018 2:09 PM
Benjamin Lord
Andrew White; Sarah Moreau; Chelsia Balestra
Re: Vendor Payments

to:
Cc:

Subject:

I-li Ben, { have veritiEd that all the invoices we have wete sent $s attachments with a delivery notificstion for
each email. How far would you like me to go back and I can rc-send them to you? Mary has been in the
hospitat arrd caught it all up ycslerday. We wete wor*ing toward getting it all rsconcilgd but we havc only
receivetl uotificatiau that US Foods had been paid in the last 3 weeks and now the A'l'&T bill today. Do you
lrave an upclatecl pnid filo to share?? Also we still have people that have not been paid fiom last payroll. It has
becn a rlaily issuc that hns been a reason fol a couplc omployees to leave ernploment with us. I still have not
retumed tlre call to Stsve at the Indiann Departrusnt of Labor becausc I have rccieved us csntact from Elcn:
regarding that rnatter, Do you havs an update nn lhat status as wcll?
I also had a family metnber $ay they were goingto file a cerntplainl with the State fornot cashing their
checks and causing unnccessary sil'ess on their parents. Another resident is voicing they are seeking legal
consult cn their status ancl payment ohligations.
Plcase advise.

'Ihank you,
Muy Watkins

5el1 li'orl rrry Sattsuttg Galaxy srttal'tphonc.

Original message
Benjamin
l-ord <blord@elcm.corn>
From:
Date: 9ll8ll8 1?:09 PM (GMT-05:00)
'l'o : Mary Watkins <lmwatl(ins@nhseniclli vi ng'com>
Cc : Chelsea Balestra <cbal estra{Selcnl.eom>
Sub.iect: Vendal Payments

IIi Mary,

A fbw things:

.
.
.

A'l&T Bill has been paid, scrvice shsuld be restored imminently
On all future emails rcgarding daily updates & vendor payments, ],ou can send them to
,llli{i.*u::lr,r:rql!. No need to send to me, Andrew or Salah individually anymore,
Regarding vendor paltnsnfs,I'm seeing that little to no actual invoices have been included in the claily
updates for seveml weoks. Were they maybe ssnt lo other people? If nut, we nced them to make a dent
PAGE 218

 in the vendor pnymeirts. It would be best to stsrt wift ths highest priority palanarts we necd to maka
todry,

Itnppy to discuss ifyou have any qussfionr.

Ben

Iord

Bast LBks Capit*l Man*gonent
1920 McKinney Avonug Suite 700

Dallas,TX7520l
blord@elsnLcom

Cell: 602-989-0652

SEsstLqke
Cst

lltl

I'''riltrqmsnt

2

PAGE 219

 EXHIBIT 

ROY COOPER

NC DEPARTMENT OF

HEALTH AN D
HUMAN SERVICES

.

Governor

MANDY COHEN, MD, MPH
MARK PAYNE

.

.

Secretary

Director, Division of Heailh Service Regulation

NOTICE OF INTENT TO ISIiUE A PROYISIONAL LICDNSA

CtrRTIFIED MAIL
#?016 2140 tl00{t t}372 2564

Andrsrv White, Executive Officer
SH Regency Charlotle l-easing, LLC. l,icensee
R.cgurrcy at Pineville

TO:

9i20 Willow Ridge Drive
NC 28?10

Charlofte,

ttw

FR0M;

Meg,an Larnphere, MSW
Chief, Adult Care l,icensrtrc Section

RE

Intent to Issue Provisionnl License
Facilityr Regency at Pineville
f ,iccnsur'$ Nurnber: IlAL060-l 39
Counfy; Mecklenburg

l)A'l'k.:

August 29, 2018

ACENTJY

DICISIO\

PLEASH 'IAKE NOTE thal the Nr:rth Carolina f)eparlnrent of Healtlr and Hunan Services. l)ivision of'Health Service
Regulation, Adult Care L.icensure Section has deterrnined that you have substantially lbiled to ccrnply with the provisions
of Articles I and 3 of'Chapter l3 I D of the )llorth Carolina Ceneral Statutes and r.r'ith the rules adopted pursuarrt to these
arficles. '1-herefore, the l)epartrnent intcnds 1o downgrade your licerLsc to provisional stalus.

The agency's decision i* based upon thc lindings in the *\taternent of l)ehciensies dnted August ?, 2018n which has
been mailed or provided to you. If you need a copy of the document(s), plcase cont{ct our officc at (919) 855-3765.

NO'I'ICE OP OPPORTUNITY TO DEMONSTITATE COMPI,IANCE WITI{ LIf]NNSL-RE RTILI,S
llursuant 1o NCI General Statute l50B-3{b), you *re herehy given an opportunity to show corr:pliance rvith all lawful
requiremenis fcrr refention of your license. If 1'cu believe thal you have substantially ccrnplicd nith licensing laws end
rules, you rnay submit a r,vritten stiltemenf to this agency. This stalement should clearly set out nll of the reasons rhat you
cautend dem$nsirate vour compliance. You rnay atrach suppotting dOcuments to your statemcnt. Send youl u'ritten
statement and any supporling documents to lny attention at:

HC OEPARTIIIENT OF

HEALll{ ANg HUMAN SERVICES ' DIVIS'ON OF HEALTI{ SSRVICE RESULATION
ADULT CARE LICENSURE SECNON

LOCATION: 801 Biggs Drive. Brorn Building, Raleigh, NC 27603
MAILING ADDRE$S: 2708 Mail Service Center. Raleigh, NC 27699-2708
www. ncdhlrs.govldhsrlacls . TEL: 91 9-855-3765 . FAX: g 19-733-9379
AN EQUAL OPPORTUNITY /AFFIRMATIVE ACTION EMPLOYER

PAGE 221

 Page ? of2
Regency at Pineville

HAt.-060- 139
August 29, 2018

Adult Care Licensure Section
Division of llealth Serv'ice Regulation Services
2708 Mlil Servirc Center
Ral*igh, North Carolina 27 699-27 A8
ln order to

be considered.

your written staternent rnust be receivcd by this agency within ten days after thc mailing of

this notice.

coNsEQtixNcE

or

TAILURD To suBlltrTtryRITTEN STATEMENT

If thc agency tloes ncrt receive a rvritten statemenl from you within ten days after the mailing of this notice, a provisional
license will be issued. If the agency receives a written statemenl rvithin thc time specified, the agency rvill carefully
review and will render its decision.
You ntay call me ill (9191 855-3765 if you have any questions about this notice ot vour right trr show conrpiiance \,vith all
Iawful raquirements for retention of the prcsent status of your license.
F,nclasur$s
cc,

Scolt Sutton, Administrator, denclosures {included in eertified rnailing #70:6 2140 0000 0572 ;564}
I)an Coverf , Regiana I D i rector, dcov$rttgelcm, c 0m
Mark Rowc, Supervisor/Designce, M*cklenburg County llSS
Conslructiun Seelion, Division ol Health Servicc Regulation
Libby Kinscy, Assistant Chici Adult Carc l.,icensue Seelion
't'ichina llamcr, llirector of Programs, Adult Care Licensure liection
Tameka Riggstrce, Program Manager, Adult Carc Lieensure Section
Linda Blalock. Branch fvlonagcr" We.stem Region, Atlult Care Lieensurs Section
I{eather binghatn, 'l?arn liupervisor, Wesl 2 Region, Adull Care Licensure Sectiorr
Paulelle Bnrck-Fogg, "Adu.lt Care Liecnsure Seetion
Ralcigh Facilfy File

NC DEPARTMENT OF HEALTH AND HUMAN SERVICES . DTVISION OF HEALTH SERVICE REGULATION

ADULT CARE LICENSURE $ECNOH
LOCATION: 801 Blggs Drive, Brow! Building, Raleigh, NC 27603
MAILING ADDRESS: ?708 Mail Seruice Cenler, Raleigh, NC 27699-2708
wwyt/.ncdhhs.govldh$f/scls . TEL: 919855-3765 . F X: 319-733-S379
AN EQUAL OPPORTUNIW / AFFIRMATIVE ACTION EMPLOYER

PAGE222

 NC DEPARTMENT OF

ROY COOPER

HEALTH AND

'

Governor

MANDY COHEN, MD, MPH

HUlrlAN SERVICES

MARX PAYNE

'

.

Secrelary

Uirector, Division of Health Sersice Regulation

Cerrified Mail and Electronic IVIsil
#?016 2140 0000 0s?225s7
Arrgu"^t

29,zlttl

Andrew Whiie, Executive Officer
Sl"l Regency Charlottc Lcasing, LLC, Licensee
Regency at Pinevillp
9120 Willo\ry Ridge Drive
Charlotte" NC ?8210
E mai I :,\i s ut tt tt(&nh s enior I iv i ng. ut trt

dutverl{ciie I e,n. c a$,
RE:

Suspension $f Admissions
t'acility Name: Regency at Pinerille

Licensure Number: HAL-060- 139

County; Mecklenburg
lJear Mr. White:
tsased crn the infomration ancl lecommendatisns submifted Lry our stalTand the Mecklcnbury County l)epnrtment e'rf Social
Services, rve lind that your faoilitl, has failed to carnply with Articles I and 3 o1'{Jhtrpter ll ll) ol'the North Canrlina
Gerieral Stntutes and the rulcs adoptecl pursualr io these articles.
'l"hc docunrented violations indicate that conditions in lhe lrorne are fbund to be detrinenrnl to the hea]1h and safety of the
residcnl s. I here fore, you are hereby orclered fo suspend all adrnissions to the honre el fcctive irnrretlialeh,. I'he
Suspcnsion ol'Admissions is to continue until conditiclns or e irtumstances meri{ renroving the suspension.

The agency's decision is besed upon the fintlings in the Statement of Defieirncies dated Augrrst 2, 2018, which hns
alrcndy been mailcd or provieled to you, If you do nat have n copr uf the docunrent(s), please contart us at (919) 8553765.

Snsnension of Adlnissions

Anoeal Notice
You have the right to sontest the ubove action within Xfl days after lhe mailing of lhis notice, in ac*ordance with (i.S.
I508. Article 3 and 6.5, l31D-2.7. Shctuld you decide lo appeal the above adverse action, please be advissd that C.S.
l50It-22 encourages the settlemcnt of disputes through infonnal procedures lo assist in resolving any dispute you rnay
have rvith our findings or propersed aotion.

For conrplete instructions on filing of petitions, please contilct the Ofllcc olAdministrative Hearirrgs at (919) 431-3000.
'l'he rnailing address frrr the Office of Adrninistrativc Hearings is as follo',r.s:
NC OEPARTMEiIT OF HEALTH AIID HUIi'AN SERVICES . DIVIS1ON OF HEALTH SERVICE REGULATION

ADULT CAR€ LICENSURE SECTION
LOCATION: 801 Blgge Drive, Bmwn Euilding, Raleigh, NC 27603
Maal Service Center. Raieigh, NC ?76SS-2708
www.ncdhhs.govldhsrlacls . TEL 913-855-37€5 . FAX: -o19-733-S379

MAltlNG ADDRESS; 2708

AN EQUAL OPPORTUNITY /AFFIRMATIVE ACTION EMPLQYER

PAGE 223

 Page 2

of3

Regency at Pineville
r'rAL-060- I 39

August 29,2018

Offfce of Administrative Hearings

M*il $ervice Center
Rdeigh, NC 27699-6?00

6714

$ l50A-21.2. Fee lbr fililrg n csntesled casc hearing.
(a) tiling Fee. -- ln evely contested case conrrn€nced in the Office ol'Adminisfrative llearings by a person aggriwed, thc
p*titioner shall pay a liling tbe, and the administralive larv judge shall have the aulhority to assess that filing fee against thc krsing parg'.
in the anrount i.rf one hundred twenty-five dollars ($125.00), unles.s the Offi{r., of Administrative Hearings establishes a lesser filing fee
by rule.

ib) f ime oi'Collecticrn. - All f'ees that are requiredtn be assessed. collsct,3d. and renrilted under subsection (a) of this section
shall be collected b;,the {)lfiee nf Adnrinlstrative Hearinps ai the time of cornrneneement olthe conlested case {except in suits in frinla
pauperis).

(c)

Forms

cf

Payment. '" Tlre OfTicc of Adrnini.stlative Hearings mny by rulc prnvide far the acceptable forms for payment and

transnrission of the filing fee.

{df

Wavier or Refund, -'l'he Oftice of Adrninistrative Hearings shall by rule preivide lor thc lee to be weived in a contested
l-ll0andinacontestedcase
case inwhichrhepsfitionisfilcdinfurnrapauperisandsuppoltedbysuchprurlsasarc'requiredinC.S.
ilvolving a nraneiated fedsral cause of actiarr. I'he Oftice of Adnrinistralivc Hcarings shall by rule provide lor tlte lee to bc refunded in
a conlested case in which the losing party is thc Statc. {2009-451, s. 2lA.l (b).}

N.C. General Statute $ l50B:23 prcvides that ycru mu$ also serve a copy of the petition on all ather pal'ties, which includes
the nepartrncnt uf Health and flulnan Services. 'l'he Depanrnentos r€presenlative for.cuclr actinn is l,isa C. Clorbett" Geleral
Counsel. 1'his person may rcceive service of process by mail at the following address:
L,iua G.

Corbctt

Departrnent ol'Eeelth and IIuman Services
OIIice ol' Legal Affairs
Adarns lluilding
2001 Mail Scrviccs Center
Raleigho ii{C 27699-200f

If you do not lile a pelition within the 20 day period, you lose your right tn appeal. ln addition to 1.our right to ille a petition
of a contested case hcarilg, N"e. Oeneral Stalute $ l508-22 cnc(rurages the semlcrnerrt of disputes througlr inf'ormal
procedures. ln kecping u,ilh this law, this office rernains readily available for discussion or othsr inlormal procedures t.<:
assist in resolving any disp*te yox may have with our findings and action,
Should you have sny questions regarding ally aspsct of this letter'. pleue do nol hcsitate to sontact rne at the Depaffrnent
of I lealtlr and Hurnan Services, Division of Hsnlth Service Regulation, Adult Carc Licensure Sectian, ?708 Mail Service
f)enter, Raleigh, North Camlina27699-2708 or call nie at {919} 855-3765,

Megan l,arnphere, MSW
Chief, Adult Carc Licensure Section

}IC DEPARTMENT OF HEALTI{ AND HUMAN SERVICES. DIVIgION OF HEALTH SERVICE REGULATION
ADULT CARE LICENSURE SECTION
LOC,{TION: 801 Sigga Orive, Brown Buildrng, Raleigh. NC 27603
MAILING ADDRESS: 2708 Mail Seryice Center. Raleigh, NC 27699-2708
www. ncdhhs.gov/dhsr/acls . TEL. 91 €-855-3765 . FAX: I 1 9-733^9379
AN EAUAL OPPORTUNITY / AFFIRMATIVE ACTION EIUPLOYER

PAGE 224

 Page 3 of3
Regency at Pineville

HAL{60-I39
August 29,2018
gc:

Scott Sutton, Administrator, rvlenclosures (included in certified mailing #?016 2l4A 0000 0572 255?)

NHI-REIT of Axel LLC, Building Owner
Victor Orija, State LTC Ornbudsman, Division of Aging md Adult $ervices
Special Assistance, Divieion of Aging and Adult Services
Construction Section, Divisian of Health Servise Regulation
Mark Rowe. Supervisor/Designee, Mecklenburg Ccunry DSS
Libby Kinseyn Assistarrt Section Chief, Adult Care Licensurs Section
'l-ameka Riggsbee, Program Manager, Adult Care l,icsnsure Section
l,inda Blalock, Branch Managor, Western Region, Adull Care Licensure Scclion
Heafher Bingham, Team Supervisor, West 2 Region, Aduh Care Licensure Section
Paulette Brock-Fogg, Adult Care Licensure Section
$tar Rating Prcgram, Aduh Care Licensure Sectisn
Raleigh Office Facilfty File

I.IC DEPARTTTIE}IT OF HEALTH AND HUiIAN SEBVICES'DIIIISION OF HEALTH SERVICE REGULATION

ADULT CARE LICEI{8URE SECTIOT{
LOCATION: 801 Biggo Drlve, Brotivn Bullding. Raleigh, NC 27603
lr4AlLlNG ADDRESS: 2708 Mall Sarvic€ genter, Rsleigh, NC ?7€99-2708
www-ncdhhs.gov/dhrr/acls . TEL: 919€5$3785 . FAlt 91S-733.93?9
AN EQUAT OPPORTUNITY / AFFIRMATIVE ACTION E}'PLOYER

PAGE 225

 rq*,T:::L-%t,no
Btuirion nf $esltt Srnrirs ilryuklion

Effeetive September 10, 2018, this provisional license is issued to
SH Regency Chorlotte Leaslng, LLC
to operale an Adurt Care Home hnown as
Regenqt st PkePille
Iocated
Ch

at 9120 Willow Ridge Drive

arlotte,

NC, Mecklen burg Co unty.

issred subiect to the ststules af the Stote of North
Carolina, is not trrnsfersble und shall expire

Thls license

is

December 8r 2018,
License Namber : HAL-060-I t

*ttt'

I?,lis

I

home serves only elderly peFsons,

***

Capacity: I19
Special Care

(Inits:

ltu+

X

Yes

- No

Ilpe:

Alzheimer's/Dewentia

p

Authorlzed,bv:

Secrery, N,C. Doprrtucnt of Health end
Eumrn Sorvlcet

Dlreclor,

of Herlth

Regulrdon
PAGE 22S

 ROY COOPER

NC DEPARTI"IENT OF

HEALTH AND

.

Governor

MAt'lDY COHEN, MO, ltllPH

HUhIAN SERVICES

MARK PAYNE

.

$ecretary

Director, Divislon ol l"lealth Service Regulation

CERTTF'IED MAIL and BLECTROFI C
,?7018 0040 0000 224s

.

MAIL

6u9

September 10,30lS

Andrcw Whitc, Exesutive OfJicer
SH Regency Charlnile l,easing, LLC, l,ic.ensee
Regency at Pincville
9 1?0

Willorv Rielgc Drive

Charlolte, NC ?8210
E ma i l : dc av e* (4)e lcm.

Rc:

a0

m

Provleionnl Licenre
Facilify Name: Regency a( Pincville
Liccnsurc Nuruber: IIAI-060-139
County; IVltcktrenburg

Dcar Mr. White:
Accnrcling to thE O.S. nlD-2.7 the Department nay smend a lieense by rcducing it frorn a fuil license to a provisional
"
license for a period of not more than 90 days. The llepartnent may extend a provisional licensr fbr tot morethan one
*dditional 90.day period upon finding that the lioensee has made substantial progrcs$ trlwards rernedying the licensure
deficiencies that caused the license to be reduced to pnrvisional status. The rnaximum fime allcwed by
operate uniler a provisional licettse is 1 80 days,

lar,v

for a facility to

llased on thc information and reconmcndntions repo*ed by our stalT and the Mecklenburg Countl' Department of Social
Services, we find that your tbcility does neit comply with tlre provisions of Art'icles I and 3 of Chapter l3lD of the North
{"larolina General Statutcs and rvitli the rules adopted pursuant to these articles.

The ag*ncy's decisiun is based upon the lindings in the Staterucnt of Defici*ncics dated August 2,2018, wltich has
already bcen mniled or provided to you. Ifycu noed a copy afthe document(s), please contact us at (919) 855-3765.
ln nrdcr to allo*,you n r€asonatrle tirnc pcriatl in which to bring your facility into compliance with ninimum rules, we are
issuing a provisional licensb fo Rngency at Pineville, HAL-06{ -139.
'l.he enclosed license shall rernain in fcree until llecernber 81 2018 unlcss a change irr eonditions warranls further action.
Cnreful cansideratiun rvill bc given to rvhether ol not the facility ryill continue to br liccnssd after Decrmber 8, 2018.

The suspension of all admissions to the facilify whish wns mailed
until coaditions sr rircumstsnces merit renroving the suspension.

NC DEPARTfrIEIIT OF HEALTH

b,v

certified mail on Auugs{ X9,2018 is to conlinue

AilD HUUAN SERVICES. OIVIgIOII OF HEALTH SERVICE REGULATION
ADULT CARE LICE}ISURE SECTION

LOCATION: 801 Biggt Driva, Brown Euilding, Raleigh, NC 27603
MAILING ADDRESS:2704 Mail Servioe Centor, Raleigh, NC 27699-2708
www.ncdhhs.gov/dhsr/acls . TEL: 119-855-3765 . FAX: 913-?33-9379
AN EeuAL

oppoRTuNrry

/ AFFTRMATTvE

AcTroN

EMpLoy€R

PAGE 227

 Page 2 of3
Rogency ut Pineville

HAL-060-139
Septembcr 10, ?018

Appeal Notlce
You have the righr io conte$r the provisional licensa by filing a petition for a contested case hearing with the OfTice of
Administrative Hearings within 30 tlays of mailing this letter. For complete instruetions on the filing of petitions, please
contact the Oflice of Adminirtrative Hearings at (919) 431-3000" The mailing address for the Office of Adrninistrative
Hearings is as follows:
Ofllce of Administrntlve Hearings
67f4 M.iI Seryice Center
Raleigb, NC 2?699-6700

$ l50B-23.1. Fee for liling

- (a)

r contested care hearing.

Filing Fee. '- In every contested cass conmenced in the Office of Administrative Hearings by a person aggricved, thc
petitioner shall pay a liling fbe , snd lhe adminisfative law iudgc shall have the autharlty lo asscss rhat filing fec ngainst thc losing porly,
in the anount oi one hundred twcntydve dollan ($ I 2J.00), unless the Otfice of Adrninistrativc I lcaringr cstnbllshes a lessor filing lec
by rule.

(b)

I'ime of Cqllection, .". All fecs i}at arc requirccl to be assessc{ coltcctcd, nnd remittcd under subsection (r} of this seclion
shall be collected by the Office of Adninistrntiva llcarings at the timc of commenccment of lhe contested case (except in suits in forma
pouperlr).
Forms of Payrnent. *. The Office of Administralive Hearings may by role provide for the acceptable forms for payrnont and
transmission of the filing tbe.
Wavier or Refund" ,- Thc Ofiice ot'Administrative Hearings rhall by nrle provide for lhe fee lo be rvaived in a conte.slcd
case in whieh rhc petition is filod in foxna pauperis and supported by suclr proofs at ate reqtired in G.S. l -l l0 and in a contested ease
involvirrg o mandatod federal cauee of action. The Offiee of Administrntive Hearings shall by rule pravide for the fee to be refunded in
a conresred case in which the losirrg pa*y is lhe State. {2009-451, s. 2 !A.l (b).)

'

{e)
(d)

N.C, Ccncral Statuto $ l508-23 provides thatyou must also serve s copy ofthe petition on all other pafties, which includes
the Departnrcnt of Ilcalth and I luman Scrviees. Tho Depn$ment's representativc for such action is l,isa O. Carbetl" Geneml
Counsel. 'l1ris persun may rcccive service of process by mail at the following address:

Lisa G. Corhett
Depnrtment of Heelth lnd Humsn Services
Ofllce of l,egal Affairs
Adams Building
20{ll Mril $ervices Center
Raleigh, NC ?7699-2001

lf yr:u do not file a petition within the 30-day perlod, you losc your right to appcal and the action explained in this letter
will become ellbctive as dcscribed above.
In addition to your right to file a petition of a contested caie hearing N.C. General Statute $ l50ll-23 encourages fhc
seftlement of disputes through informal procedures. ln keeping with this lflil, this office remains readily available for
dissussion or other informal procedures to assist in resolving any dispute you may have with our findings and action.
Should you have any questions regarding any aspcct of this leftcr, please do not hesilate to contact me at the Deparlment of
Health and Human Sewices, Division of Heatth Service Regulution, Adult Care Licensure Section, 2708 Mail Service
Center, Raleigh, NC 27699-??08 or call me at (919) 855-3?6J.
NC DEPARTIIIENT OF HEALTH AI{D HUMAN SERVICES. OIVISION OF HEAL'H SERVICE REGULATION
ADULT CARE LICENSURE SECTION
LOCATION: 801 Biggs Ddva, Brown BulEing, Baleigh, NC 27803
MAILING ADDRESS: 2708 Mail Service Cenbr, Ralelgh, NC 2769€-?708
mn/w.nodhh6.gov/dhsrlacll . TEL: 91$835-3765 ' FNt 919-73$9379
AN FOUAT OPPORTUNITY /AFFIRMATIVEACTION

ETUPLOYER

PAGE 228

 Page 3 of3
Rogsncy at Pineville

r{AL-060-r39
September 10, 2018

Chief, Adult Care Licensure liection
Enclosures: Provisianal License
cc:

VictarOrija. State L'fC Ombudsman, Division of Aging and Adolt Serrices
Spccial Assistance, Ilivision cf Aging und Adult Services
Construction Sestion, Division of Heahh Srrvice Regulation
Glenn Aicllo, Adninistrator, wlerclosurer (inclndcd in certified mailing f 7018 {040 0{00 2245 6l 19}
Libby Kinsrn Assistant Chiet Adult Care Licensrre Section
Tichioa Hamer, Director of Programs. Adult Carc Licensure $eution
Tameka Riggsboe, Frogram Managcr, Adult Care Liceosure Scction
Mark Rowe, SupavisorlDesigrrrc, Mecklenburg Counly DSS
Linda Blalol( Branuh Manager, Westem Regio& Adult Csrs Licensure $ectirxr
Hoother Bingham, Team ? Supen,isorn Adllt Care Licensurc S*d$n
Faulette Broek-Fogg, Adult Care Licensue Scelion
Raleigh Faciliry File

ilC

DEPARTTTIEI{T OF HEAL?H AND HUIIIAI{ SERVEE$

. DMSION

OF I{EALTH $ERVICE REGI'LATIOT{

ADULT CARE UCE}IsURE gECNON
LOCATIOM 801

Eig$

Ddv6, Brounr Buildlng, Ralelgh. NC 27e0g

MAlLll{G ADDRE$$; 2708 MailSlwice Centor, Ralabh, NC 2739S.2708
um.ncdhhs.gov/dttct/aclr . TEL 9l+85$378tt . FA)t 91 8-733.9378
AN EQIIAT OPPORruN TY/AFFIRMATTVEACNON

EfuIPLOYER

PAGE 229

 Charles M. Walker
U.S. IlanltruPtcY Jutlgc

Daled: A/21/?078

IN T}IFi UNI'fE1} STAIES I'AI\JKRUPTCY COURTFOR
]'I-IE M]DDT,E DISTR.IC:'  OF I-ENNESSETJ

IN RE:

)
J

t

Case

I

Chapter

t

EI,I7.,ABI1T}I ANN W INTER

No.

3

:

17-bk-04,573

13

l

SSN: XXX-XX-7099

It

Jr,rdge

Charles lv!. Waiker

l
tl
l

Detrtor,

Illieabetli Ann Winter

i

)

I{aintilf,

1

I

I

I
I

Adv. Na. 3:18-ap-9005 I

.a

lI

J

[]as1 [.ake Capital Management Emplaycr',

L'1.,C.,

l
)

I-lefendant.

)

ORD[,lt X'$'lDlNG DSFENDANT IN C:O$T,EMP' 'Or fRIIVIOUS COURT ORDER$
AND AWAIIDIN{; SANCTION$ AND OIII)I,R GITANTING TTJRNOVAR OIT TSTATE
rROT'trRTY
J'his mattel was originally brought before this Court upon th{}

filing ot'a Colrplaint for

'l'unrover and ltequest Jbr Sanctions against Defenclant llast i,ake Capital Managemettt Employer,

I.l,C fbr their lailure to remi{ prflperty of the.estate to the Chapter 13 Trustee, A stimnons

to

an$wer tlre con:plairt was issued to the Del'er:tJarit alrd a pre-lrial conference wits set in the rnatter'

The llefendant failed to answer the comgrlaint or appear

a1

thc irre-ttial couferetrce. As a resulf,

the Debtor, by nncl rhrough Counsel, lileti antJ expedited motion fbr an arder cr:nrpelling Delbndant

tu appear ancl show cause as to why they should lrot be iicld in contetnpt for failing to appear and
answer.

A hearingwas scheduled on Jr.rly 17,2{)18 requiringthe Det}ndant to appear

gause fls to

nnd show

why thcy failed to answet or appear. At that hcaring, the Court cQntinuecl the motion

Case 3:18-ap-90051

Doc

L4

Filed 08122/18 Entered OBl22lL8 08:58:43
l.)nnttmpnt Fanp 1 nl 7

Desc Main

 until August 14, 20lt{ and diresled an Agent or Manager of [ast ["ake Capita[

Management

Enrploycr" LLLI to {rppear and show cause as to why they.should not be held in contempt. At thc
hearing on August 14, 2018, Detbndant once again .failed io appear or answer. As su*h, based upon
the

folegoing,l"f tS HERHBY ORDERED

as

1. l'he Defentlail shall immediately

follows:
tulnovsr tn ilre Chapter 13 'ftustee all funds which

have beerr wittrheld from the Oeblor's paycheck and not vernitted to the Chapter

13

l'rustee in the total amount of $3,470 00.

2,

T'he Dcfendant is h$rety lound to be in contempt of this Clsurts'orclers far their an-

going and icpcatcd vi<llations'

3, As a result of the Defegclant's

contempq the Defbndant is hereby sanctioned in the

amolrntof$I0,000.00'

4,

The Defendant shall have fourteen (14) days tionT the service of this signed Order on
the Defentlant to ilppear befofe this Court antl to sirow cause 8s to why these sanctions

should be purged as to the DeFcndarrt,

"

5, Debtor's counsel shall

ire alk:wed attorney fees and expenses

in the amount of

$2,256"30 as evielenced by the attached atlidavit which shall be paid to Debtor's
c.cunscl by thc Defendant.

6,

"f'his Honorable Court lrerebi' reJbrs this matter

to the United States Trustee

to

investigate further actian against thc Dcfendant, inclucling pnteutiai uirninal
prosecution fol theft against the bankruptcy estate.

rT IS SO (]ITDERED
This

order

wes

Case 3:18-ap-90051

elecronically ,vigned and entersd as indicoted at lhe top af

Doc

14

Filed OBlZZlLB Entered ABl22l78

l)ncttmenl Pane 2 nt 7

tke

frst

page'

'

08:58:43 Desc Main

 APPROVED FOR. ENTRY:

lsl bqnici Ca*tqgnst ^ .
Dgniel Castagna, BPR #2t721
Afrorn*y for Dottor
FlexerLaw,PLLC
1900 Chur$h 8&cot, St€, 400
Nsslville, Tt-t 37203
(615) 2s5-2893

fsx; (615) ?4?-8&{9
Ert€cj@iangsfia\crqglrE\$usrlaw,cCI4

Case 3:18-ap-90051

Doc

14

Filed 08122/18 Entered AN22lt8
3 rtf 7

lJru:rrmpnf Panp

08:58:43

Desc Main

 ]N

.I'HE

I]ANKRI .II)'I'CY COTJR'I'
Of TINNESSEE

I.INT'T'F]D STA' I:ES

FOR TI{ll. ivflDDLE DI$TRIC' 

IN

i

ITJI:

I

{)ase No. 3:l 7-hk-04573

I
t

Chapter

I

ELIUABE I{ ANN WINTJ'R
SSN:XXX-XX-7099

13

l
II

Debtor,

Judge Charles M. Walker

,
\t

Elizabeth Arur Winter

]
]
I

Plaintifl.

l
I

v

t

Adv. f-io.

3; 1 8-ap-9005 I

]
llast Lnke Capital Managenterrt lirnployer, f .I,{1,

l
l
)

Dcfendant,

AFFIDAyIT

Otr'

)

DANIELCASTAGN{ IN SUPPORT' OF APPLICATION FOI{ ATTOR {EY
FEIiS

I. Darriel Castagna, having duly been'sworn, would stal(: under oath that either I, o1' one of rny
$ssociate atiot'loys, have perfonned the .qervices provided on the nttache,l iternizecl

lisl at the hourly

ratc o{'$300.00 p,lr hour.

I, Darriel Castagna, stale that i anr applying tbr lees and costs ol'up
{bcs for rvor* perttrrrrrecl

t*

rlatc by

llaniel

tct $2,256.-10 as flttoflley

Casragna an<i any associated attorneys

al nty officc in thc

above styled Chapter I J casc.

NC}'I

FUR" I.IER, ATTIANT

Ilaniel Castagna
Attornev far f)ebtor
STATN OT TENNESSEE

Swonr nd subscribcd to bcfbre

l

this

l
COUN'IY OF DAVII}SON l

PTJBTKI_-*
ission Expires:

Case 3:18-ap-90051

Doc

14

fup -e

Filed 08122/18 Entered AAl?zlLB
rment Fanp 4 nt 7

f)ncr

08:58:43

Desc Main

 Time

Date

Callfrom client re
payments (p)

319/2418

0,10

_t.

Callfrom client

3t12/2A18

re

payments (p)
0.10

3tfil2}18

Call to Emolover re;
tpayments (p)
,

I'

0.1

l.-.

lReceived I Reviewed
ipaystubs from client
(Lefler)

u2ana 18

0

Phone call from client re:
paymen?s (p)

u26t2418

0.20

Prep / Maifed letter to
employer (Castagna)

3t27QA18

0.20

M client re
payments {Castagna}

4,512018

0

4t1212418

Review of Trustee's
Records 1 Preparation of
Adversary Proceeding i
Mailed copies (Castagna)

il1312418

Prepared / Mailed Dec of
Seru (Lefler)

2.20

I

0.20
511412018

Phone call from client (p)

lo/1 112018

Phone callfrom client (p)

0 2A

I

J

I

0.1

Ficeivea i neview oi Mfb

Et12t2CI1B

,

(Castagna)
I

0.10

Letter to client {Castagna)

6113t2018

0.10
Prep objection to MTD
(Castagna)

6118/2018

Case 3:L8-ap-90051

Doc

14

Filed 08/22118 Entered O8,l22lt8

l-)nnunrpnt Pane 5 nf 7

08:58:43

I

0.20

Desc Main

 Appearance at Pretrial
Conference {Castagna)

6t2U2A1B

t

'
I

Prep I Filed Expedited
Motion to Appear & Show
Cause {Castagna}

a2u2a18

Prep I Filed Expedited
Hearing on Motion to
Appear & Show Cause

18

i
I

i

0,00

I

I

iCastagna)

0.20
!

Filbd / Mailed Dec of
Service (Lefler)

6n6/2A18

0

0.20

Phone callfrom client {p)

7116/2018

0.10
on

11712A18

0,30
i

7n9na18
Continuing Motion to
Appear & Show Cause
tagna)

t
)

7 t24t201

I

0.20

Dec of
Service (Lefler)

0.20

8t14t2018

Appearance at Show
Cause Hearing (Castagna)

8/15/2018

Phone callfrom client
(Castagna)

0.
l

i

0.10

Prep Order Denying MTD
(Castagna)

6t2018
I
I

"8ll
i

0.20

8116t2018

Prep Order Granting
Motion for Contempt
(Castagna)

81171?018

Preparation of Attorney
Fee App (Castagna)

Case 3:L8-ap-90051

Doc

14

0

0.30

FiledAB ZZ LB Entered 08l22lLA 08:58:43 Desc Main
R nl7

l-)nnurnent Pnnp

 Mail{$6.95I01

$

36.30
7.1
0

nded
Total hours
by panlg_ggl_
otal hours
Paralogalfse celcu latod at $l 00,O0lhour

90.
2130,00
2220.40

nttolpy_f$. q *!{leF_{:!${9949t!s!tl

,Fser aarnsd
pald lnglde-th"e plan
Total 1[gpe.;1_ftge requgeted
Total Cocb I

lr;*

_

*

35.30

;ffi ,l:"i":"3"ffi
:iH

Case 3:L8-ap-90051 Doc L4

Filed autzztLl Entered 08/;;;
rmcnt Fanp 7 ol 7

f)ncr

;J;:,

:,'lilHill:'llI

arrpear 8n tha toF of, the

ililil"'oesc

rtrain

 Weiss, Bessie

SubJecti

Cota, Pamela
Tuesday, November06,2018 2:47 PM
Weiss, Bessie
George, Camille; Schurr, Stuad
FW: Sumrnary of Vermont call and follow up

Importance:

High

From:
Senl:
To:
Cc:

See below

From: Cota, Pamela
Sent: Thursday, October

04 2018 10:00 AM

To:'awhite@elcm.com' <awhite@elcm,corn>
Cc:Schurr, Stuart <Stuart.Schurr@vermont,gov>; George, Camille <Camille.George@vermont.gov>; Leavitt. Suzanne
<Suzanne.Leavitt@vermont.gov>; Clark, Clayton <Clayton.Clark@vermont.gov>
Subject: Summary of Vermonl call and follow up
lmportance: High
Good Morning Andrew,
Thank you for calling in yesterday so we could have a group discussion. As I mentioned, this email is to follow up in
writing and also to communicate what we need from you in order for the facilities to be considered in good standing
with the licensing agency. Please provide your responses bv Mondav. 10/b/18 at t0:00 AM.
Please also let me knorir, as soon as posslble, dates of when you

wlll be in Vermont next so I can plan

an in-person

meeting.
As I stated yesterday, the concernslreports we are receiving are as follows. Many of these allegations have been
substantiated during our onsite surveys and investigations.
Concerns regarding financial stability, quality of care, and quality of life from the offices of both of our United
States Senators. directly from a State Senator, lawyers representing residents of your facilities, Office of the
Long Term Care Ombudsman, Attorney General's office, residents, families and cornmunity members.
Failing to collect payment from residents for several months;
Failing to pay vendors and service providers, with vendors stopping deliveries and service providers terminating
their services to residents;
Staff paying for food and other items out of their own pockets, upwards of hundreds of dollars of personal

1.

2.
3.

4.

5.
6.

7.
8.

monies spent by staff for things like milk, eggs, bread, etc. due to the ceasing of food deliveries;
Staff turnover and resignations at a concerning rate and lack of supervisors/qualified staff;
Staff needing to work extensive overtime hours to make up for lack of staff to try to ensure the safety of
residents;
Failing to provide required refunds to residents;
Ongoing issues with failing to pay vendors/service providers since ownership change, leaving an unstable

environment;

9. Reports of and direct observation

by our Nurse Surueyor of the anxiety the above issues are causing residents,

families and staff.
Here is the list of the queslions I went through yesterday, to which we need responses:
1. A plan regarding when you will begin accepting resident payments. with a start date indicated;

I

 2.

4.
5.

A plan io systematically review any dellnquent vendor payments and service provider payments, and
immediately bring accounts to good standing with all vendors/pmviders, with a date of completion indicated;
A plan on how you are going to recruit new staffto replace resignations and ensure sufficient numbers of
qualified staff on an ongoin8 basis;
n pian to immediately refund all applicable resldents' money owed to them or their estates;
A plan to ensure, in the case of any further extended absences, your businesses are able to continue to operate

6.

without disruption;
your plan to inform residents immediately of your effo*s to rectifu the situation and your plan to be accessible

3.

to these facllities;

7. your plan to restore confidence with residentsfamilies/vendors and all other interested parties;

L

9.

An explanation of why it was impossible for you, as the Licensee of 3 Vermont Residential Care Homes, to
respond to the State survey agency and concerns from other parties for a period of at least 4 weeks.
provide a list of the nemes and addresses of facillties {assisted living, residential care, or other senior care-type
buildings - excluding independent living) owned by you or an LLC for which you are the principa/manager in

other states.

10. *new* Do you own the real estate at Pillsbury Manor South, Allenwood at Pillsbury and Homestead at
pillsbury? lf not, please provide the name and contact information for the real estate owner,
11. *new* please provide a phone numberwhere lcan reach you. The number provided on allof the applications
{917-825-1308) does not accept incoming calls.
Sincerely,
Pam

Pamela M. Cota, RN Bs
Licensing Chief/Nurse Adminisilafor
Divisicn of Licensing and Protection
HC 2 South -- ?80 State Drive

1l

Waterbury. VT A5671-2060
(8O2) 241-0347

2

 Earb
Frorn:

Chelsea Baleslra

Scnt

Monday, october 22,20L81014i AM
Barb Moynan
RE: A Couple of Questions

To;
SnhJectl

Hi Barb,
have
Thank you for reachlng out, I am hsppy to help ln eny wey that I can, Ar far as billing goes I believe Ben and Andrew
lnvoice
paylng
an
vendors
for
do
know
I
lnvolved
conver$ations.
not
in
those
honestly
plen
llm
for
tirat,
out
$orted e
needr to be provlded to Ben [prd, You are welcornc ts send them a copy to mt sr wcll or CC rne on the erilails as I do

help wlth the corporate luolcer tracklng,

flease

llt

me know if lcan help out wlth anything elsel

Chslscs Bslcstra I Sontor Rccruiting Arcoctats
East Lake Cf,Pitcl Manatsment
1920 McKinney Ave, 7s Floor
Dallas, TX 75201

Pl (972)754-3ooe
-,r*9iut'
.::.1i

I ll,]:',, l" i, i li': {':

From: Earb Moynen

tenfi sunday, october 11, 2018 2132 AM
To: chelsca Ba lestra {gblESB@SlgE{ff[>
Subfsc.tr A Couple of Questlons

Chelsel

-

{Plllsbury SenlorCommunlty}. I have a couple of
quertlo[$ that I hope you era rble to enswerfor me. I am worklng on my plan of correctlons. lf you aren't the per$on I
need to rpeak wlth lf you could send me in the rlght dlrection.
Thts ts Berbara

l, Moynan LpN. I am the current Manager at Allenwood

lWhen

r

will resldents stert gottlng bllls agaln? Who do I contact about thls. I got e daflclency for thic,
As far rl peylng vondors etc who do I talk to about thn, I got i deflclency for thie.

know that Rosemarle provetto (DONI hac been talklng to Ben or Andrew about thesc thlngs, And maybe I should bc
talklnB to Rosemarl: about thk elro,
I

Thanks for ell you do.

Barbarr J, Moynan LPN
Nune Msnagcr Allenwood

I

z7o /

6}tw

xrd

6t

tlT nfl,r 8r0a/Eal01

 -t

I

TI{O1IIAS J. DO]VOVAN, JR.
ATTONNIYCENERAI,

TELI (8oa) g4r-or89
FAXr (8o2) a4r-oa14

/wvw'ago.vermont,gov

.'OSTIUAR. DIAMOND
DEP UI'C ATTORNE"Y GF,NER AI.

WTLLIAM E. GRITT'IN
CITIEF ASST" ATT'ORNSY
GBNNRAI,

STATE OF\IERMOIVT
ATfORN T GENERAL

O}'FICE OII l'HE

a8o SrATE DRIYS - HC2N
I/YATERBURY,I/T

o567r-zo8o

Octeiber 72,2018

BvEmail and Certified Mail

Mr. Andrew White
ELCM Pillsbury Management, LLC

l4}4l

Dailas Parkway, Suite 650
Da1l.as, Iexas 75254
Re: Request fbr Fir:ancial Stateme.nts

Dear Mr. White:

Ibe Vermoat Attorney General's OfEce through its representation of the Department of
Disabilities, Aging aurl lndepende:rt Living (DAIL, licensing agency) llas received irforrnation
that raises concefil regarding the fi:rancial practices at the *uee Jbcilities thal you own. and
manage in the State of Vennont specifically: ?illsbury Manor South and Allenwood at Pillsbwy
Manoi in South Bwlington, and Homestead at Pillsbuly in St. Albans. The r:eported financial
ir:egularities include, but ar€ not limited to, failwe to pay vendors providing goods apd services,
and failure to bill or oollect payments from residents for their care and services for the past
several montlx. This situation raises duestions regarding yow operation's financial capacity to
maintain these faciliti es.
Residenlial care facilities licensed in Vennonl are required by statute arrd regulation to
clemonshate their financial solvency to the licensiug agency. ,lee, 33 V.S'A" Chapter 71 and the
Vemront Residsntial Care Home Licensing Regulations. Pursuant to that authority, please
provide"answers to the following quostibns and the requested financial.statements as soon as
passible, and no later than Monday, October 29;20L8'

l.

When

will ELCM begin

processing resident bills antl payments on a nonnal

biiling cYcle?

'

Z,
3.
4.

5.

How do you plan to collect past due anounts that were 4ot previously billed?
Are mortgage payments forthese properties up to date?
Are there any debts or iavoices unpaidpast due 30 days?
Please prnvide the most recent audited, annual financiai statemeds, including
balance sheets, inoome statements, and cash flows.

 t

6,

Please provide the rbost recent quarterly frnancial sbtements, including balance
sheets, inoomc statempnts, and cash flows.

Coatinued.safe operation of these residences is vitally importantto Vermont' Please
submit these statements io me at beseie.weiss@vermontsov. If you have any questions
eonceming this reques! yon may email or call me at (S02) 241'A29fr. Thank you for your
cooperation with this mafter
Sincerely,

fu*;

Bessie'Weiss
Senior Assistant AtbnreY General

Monica Hutt . DAIL Commi ssioner

 .10/31/2019 wE0 15t 06

FA]i

PILLSBURY
IOUTH CAMPU5

October 31, 2018

Mary Bolton

BN

Division of Licensiry and Proteetlon
HC2 South, 280 State Drlve
Waterbury, VT 05671
Dear Mr. Bolton,
Attached plaase find the revited Plan of Correction forour Plllsbrrry Manor South rite visit on 10ll/18,
Plaasa fuel free to call with any further guestion:.
Sincerely,

Provetto RN-BC
Director of Nursing

7*at

?tlrrsunY MAHoI SOUT]I
20 Ho/bor visw Rsod
Soulh Burlinglon, Vl 05403

AtttNvtooD
?0 Allen Rood

Soulh Burlinglon, VT 05403

tr{}2.86:J./tl?/ lv/wv/.t.'lll$t)\,rysirlllor(;r)rr\rlrr,rriliei,LLrrtr

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An unannounced on-site $urvey was $pmpleted
on l0m/{8 by lhe Vermont Division of Llcensing
and Prglectlon, The purpose of tht $urv€y was to
invsstigats 4 oornplainls and I faclllty mandated
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to or al lhe time of admisslon, cach
residenl, and the resident's legel representatfue ll
sny; shall he prqvided with a wrltlen admission
agraementwhich deserlber th€ daily, weehly. or
niontrly rate to be eharEed, e dessriplion 0d the
services thal are covered in lhe role, and all
applicahle'linanciel iusues, including an
explanation of tfie hOrnCe policy regarding
dlscharge 0r tran$ter when s fesidenl's linancipl
elatus changes from pdvately paylng to paying
wlth S$l orACC$ benaflls, Thl$ admission
agreemenl shall specify al least how the
services willba provided, and what additional
clraqes lhere rMll be, if any: all pereonal cels
services; nursing $elvices i medisailon
managimenl; laurdryl tmn$portation; toiletries:
and any additionalseruices provided under
or s M€dlcsid Waiver program, lf applicahle, the

tht rc$dent's lransfer and dlscharge

The corpot8te tearn hes been
contasted vls amail0n odober
a8, 2018 as wellas loday, Oclobsr
3r, ?01€.As ottoday, I have not
received a r6$pon$e reguding
this deficlency

dghts,

tncluding prsvisions for refund*, and mus(
e degcrlptlon of lhe home'6 pareonal naeds
allowance policy.

(li

ln addilnn to goneral rsskient agreement
4reerfl6nts for allACC$

requlremen

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TAOOfiAf ORY DIRECTORS bN PROVIOER,SUPFLIER FEPRESEN'ATIVS'S SICNAruR€

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Rr04 Coniinued Frorn page 'l

parlicipanta

shall include: tlE
ACCS E€Nices, lhe specific ruom and board rete,
ths amount ot peIsonal nG6d3 allo\tance and lhs
priovldn/s 0Ersemsnt to accept room and board
ryrd Mcdicnid as gols Poyment.
Thie REQUIREMENT is not met

ar evidancod

b!,:

Eased on mulllpl€ lrrPorls from rssidsrrls ot lhe
th6 facixty, the lEcllity hos failed il'$ llducisry duty
locomply wlth the lsrrne of th€ idmleslon
rgrcemints to allcrrrent tegklents of the lacility,
by faillng to bill rnonhly lor rert and
magc€lla$(xJs chBrges tot each residenf$
aparlmant and agreed upon c6te and servlcag.
This rsgulatory vlolalion allecte dl rssldent9
and/or thelr legally rosponsible flnanclol partios.
Findingr lnclucle:
Per brterviowa 10nr18 end 1013/18 wilh lacilily
residents and staff, tha lacility lioensee hae fuiled
to adhsrs to he lerfis of lfreil Admicaion
Agreemenm lor all cttrenl residsntS. Thc lacility
trae taiteO io send al r€sidents a monlhly blllot
the amounl ored for rent end mlFcollgneous
chargea every month, aa gtgled ln ths ffitt€n
termo of the signed admission egr€emenls. Thig
lallure lo compty wilh the agrBomenl alac violeles
each regidenrs righl to r8vlew lhelr tinandal
f€cords upon request" Tie feelllty llcensee nas
not Bxplainsd in wrillng lo all residente tho
reasons lot theirfailure to oompty wlth the tsrms
ol eaeh admtssion agrocmalt and lhie iseua ls
causing signilicant dbre$ to r€sidente std/or
their legall! rosponsiblo partiee, Per lnteryiow on
10/2/18 wilh a residenl who wiehed lo be

STATE FORM

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(EASH CORRECTTVE ACTToN SHOULD Be
CROSE-REF(R€NCEO TO Thts AFPROPiIATE

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racdved furASl, 2016 to ha plssonl month,
sspt€nbcr, 2018., There ar€ no facillty slaft
amployid at lhe facility to fdcilitate fispon$es to.
qusitlons the reeldenb may have rbFrdlng thair
linanciEl rscords and monthly hllling hletory,
R12! V, RESIDENT CARE AND HOME SERWCES

Rl23

€$"b

The corporate ieam h6s been contacted
ue effrall on October 28 2014 as w?ll as
today, October 31, 2019. As of today, I

havo

$.4 Refundo

ngt rselved a

respsnBe

regarding thtg delrciency,

5.4.a l then a reddcnt ls dlscharged., the
rosident ehall recsive a rsfund, wllhlh lS daye ol
dltcharge, fsr any lunde pald ln advance for sach
day car6 wae nol provided, h the cags of a
disEharge to a hospital or other lemporary
placemont. the Bffsctlve date lor file provlalort
shall b€ he day ths home ls notified lhe rBEld6nt
wfll nol be rehmlng. For lhe purposes of
prcviding refunds, "day of dischargo' shal bc
consldered lh'e day the resldenls room is emply
ol the rosldent's belongings. il those belongings
arE too large or dlfflcult lor the h0m0 lo storo
temporanly. rh6 faciliiy shall temporarlly ttora
omallitemc such ss clothing and othff personel
Iterns if necersary.

Ihis REQUlli€{\tENT is not tnel es evidenced
by:

Based on intervloWs and recod r€vt€Mrs, lhE
facility failed b relund rnoney owed to ihe
estate/heire of I appllcable residena in the sarnple
alter the resldenl's oeath in February, 2018.
{Residant #5). Findlngs include:
Per teltrhondlntarvlew with Reslclent #5's f6rnily
member orr gl?9118 at 1:20 FM, h/hgf mother
died on 21&116 and s/he had vacStsd all of lhe
mstha/s belonglngs by 2/fff18. Fer interuierlv
sDqTE FORM

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wth a bu$iness office Elafl member on

SUrvEY

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ItREirAooResg, ctTY, gtA?E zlP g€De
AI HARBOR VIEWROAO
06603
BOlrTh FVRLII{GT{}N,

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RFSUIA?ony oft L8c l0GN?IFYING lt'lFgllMArloN)

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10/3118 at

?:S0 PM, shc stetcd she did not have any direct
knowledge of the billlng system or any resldents
\"ho may be owed e refund upon diEchelge hofi
l}a lecility. However, aha wae sble to sha\,r, the
eurveyor remeining documents h a llla rcgardlng
Reeldent#5. The documents included d Deposil
Recelpt entilled "Rsfundnbh Sacurlty Deposit

Arnount; $42m.00,' A Slalgmsnt dalad hnhfiV
Btated lhst ths "Total ouE' to the rcridcnt uFon
digcharge wae S6,59e.61. (Thle amount included
thg sccurily deposlt Gfund ot $4?00.00. plu$ lhe
money owed for unused days paid in advance for
February, 2018. The amount of unused daye {0
days) paid in advanca uns $1,396,61.)
A survey compi€ted on 7/3/18 clled a regulslory
vlotation dus to he failure to ralum the reeldent'a
owof rnoney and he facility wrole in a Plan of
Coracllon accopiod on 7/3111S thpt they had
refunded the rnoney owed on 7llsll0. However,
the famlly memlrcr conllrmed on 6/2O18 that no
refund had 6ver been receivod by he reeldonf*
estat€.

It

I
ll

This lacl( of sorrection of lhe regulatory viofation
represente contlnued non-compllence by tha
facitity. The fuilutu to return ths rgsadonfs funds
wlthin {5days old'ncharge lras confirmed durlng
intervlanr with bushees offtce stsff atd the DNS
on aftemoon'd 10/3/'!8.

Rl2e V, RESIDENT CAREANO HOME SERVICES

R116

1. Resdlent#1 no longet resdies

$S=G

2.
5.S GsneralCare
6"5.a Upon a resldent's sdmission lo e
rEEldentlal cerc h0il18, nccessaiy s€rvicos ehtll
be provlded or Hnailg€d to rioet th€ rcsident's
STATE PORM

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the faclllty
Raview of cuffsnt rssidents with
nursing $taff dnd tecofd revieu,
wl[ be mnducted to ensure
resdlent care neede are mgt

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R1?6

per3onalr p$ychosociel, nulsing and mcdlcal care
needs.

conlhucd from pagF4

r.

'lhla REQUIREMEIff is not met ss evidenced
by:

Bascd on lnterviews and tecord leview, the
lacillty talhd to assure thal 1 ol4 resldents ln the
hmetad sEt,trple received th€ ooc€sssry care ic
addr'Irrs theh nursing and rnedical care needs.
iRscid€fit #1)- Findings includs

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'SENTIFYINO

R126 Continued From page 4

{x$l
COMPLqTE

Education of nursing $taff witl
lnolude appropriale cornmunication
and documantation of rEsident/
family concerno by November 28,
2018. Education of care providers

willalse be cuductod to ensure
resident care necds aro belng mot

4. Audits willbe conducted by
reviewing ehilt report and nursing
progress notes weekly x 4, lhen

Per gtalf inietviewg and tccsrd rsview, nursing
eleff talled lo ehow evldencs of n€c€ggary
gsses8ment and monltoflns of cer6 fol Rcsident
#1, who wsE dedlnhg in heath gtetus fo. a period
of rreeks pnar lo oelng admilted to lhe hospital
lrorn an Eo visit on S/11rlA with s diagnosis of a
udnary tract infection, dehydratlon and posaible
sepslE liepsis i$ a pot€ntially lile{hreatenlng
compllcallon of an infactlonl. A lirne line of the
{,evelopments $howlng thg resldent's decline and
leek olconsislent c*ra and monitorlng i* included
ss follows:

monlhlyx3sndongoing.
S. The Firector f Nursing or designee
will monitor for compliance.

6.

Compliance wiltbe oorfipleted by
November 0, 201t

1, Per record review, on 8128/1 8, th€ regident's
son topoftod to th$ flul$b thst the resldent
compleined t0 h/him thsl slha w8s havlng a lot ol
pain in lhe righl tih srea, along with coughhg and
white eputum. The nurse went t0 soe tho resident
and wrote that lhe re$ld6nt moy have pulled a
rnu8cle wlth hlhar coughing and the nursp ask€d
the tha MT (mdicatibn technician) to give h/her
PRN (aF ne€ded) Tustln. The nurse did nol
docurnent any physical EsEdgsrnant of vltal slgnE
nor lung sound$ 8nd did not notlfy tfie provlder of
the change ln symptoms
2. On 9/3/t8, lne nurse wrote "The resident
con{nues h not loolw€ll thit lrofning, dld Btart lo
8TATE FOFI&I

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DE}.ITIFICATIO}I IiUMBER:

NAME OF PROVIPEROR $UPPTJER

PTLLSSURY

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$OUTHEURUNOTON, VT O34Oi

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R120

wall( t0 breakfatt but aoemod lnsteady and
wsntod to ralurn to vher apartmant.'
3. On 9/5118, alter noulioation that the reeldenl
had illd to thE floor, the PCP tprlmary care
prc)rild€o ord€r€d thgt thc rssidont g0 to the
Uroent Care for lV lluide end work up. \Mtile at
thd Urgent Care. the resident was diagnosed wilh
dahydratlon and hypercalcernle and returnsd to
tha facility with ord*s ftom thc PCP to nsllfy
thgm lf lho roEldont had any vomitins or diarhsa
0rworr.nlng ot symptoma pti0r t0 Monday {date

sn0,1s).
4. On S6/16, s rurse docnrmented that th€
residenl wse inoontinent of a large arnount of
EerntlooEg stoolE. Thrre wa$ no evldence that
the PCP nres nollflad of lha loosd 8toolE on
9/8/18, pFr orda€. Allhough lhc rmldontreported
fevrnr eymphmg ovHr lhe nsxt 2 deyB, t/ho
contlnusd wlth mininal food/liquid intake.
5, On 9/tt/18, ths rsBldent reported nol teeling
nnol
rivell,
eating/drinklng & hNd toma wmltlng,
Spoke to son and ho asBod $ac nurse h cnllihe
PCP lo sae what they uisnled to do, They ordaled
regident be sonl to ED via ambulance," The nole
shled Viial $igns (V$) at lhal time Yvare Temp' 99,8, Pulse - 80, resplralions - 20, Blood pressure
. 14im8, arlj uxyged saturalion tsv6l .90t4 (low).
No VS w6r6 documcntcd fot 0/9/tE ond 9/10116,
and continued deareased orsl lntake was noled

t
I

both ol tlnee days.

I

The nuning documenlf,$on reflEcted a hck ol
ongdng documeniad tsseilrnent of the rssident
on b rcbulEr baslg aftet the reeident rcportgd
gnd a lack of
'taoling urnvell'on 8128/18,
nollficatlon to lhe PCP in a ilrmly tllanngr ov6f
scvcfldldayc, unh* pfomgted to do so by iha
famlly. Nur86s lall€d to wtitc a follow upxur€ing,,
notebftg the rssldenls compbini on C28/28 of
Th€
and lnoresssd
rlb arBa

STATE FORM

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Continuad Fr,om page 6

neil docum€nled note wa8 deted gr2r18, whbh
stated th6t the resldeot
documented V$.

w*r

nEt

fealhg well and

Per phons lntrrvlew wlth fte rsaidinfs f€rnlly
rrnemher on 9/28/18 at 12;55 FM, an Ernergancy

Oepa4meninurse slEted to h/him that when lhe
rasldenl wag examhed in lhe ED on 9/11r18, lh0
residenfs brlst u,es soaked with urine and tec€g
and 'disintegrated'when the Eo nurse touched it
to removi it, The nurse also slnled thqt there wEs
dilcd fcqcs in the reeldenl'o Senltal gteqs. Tha
nurs€ stat€d {18t the bflef had not been changed
in a long time. Tha son $tated lhat the residenfs
care plan stated that s/he wa* to be checlced for
lncontlnence end toileted every ? houre.
The lack of appropriatd and tlm*ly car€ ln

accqrdancEwilh the plafi el care end provHer
orders ws$ conflrmed during inteMew with lhe
DNS (Director ot Nurses) on 1013118 at 6;30 PM.
Reiar also to &160.

R'

V. RESIDENT CARE AND HOME SERVICES

Rr45

1"

Regidents # 1, 3 and 4 care Plans
havc becn ooncctctl to roflect the

2.

The Diredor of Nursing or
designee will review currenl
r€sid€nfs carc pl6nE to €nsuro
rosidenfs nesds are being mot,
The Dlrector of Nuruing or
designee will audit oure plano
weekly x 4, then rnonthly x 3 and
ongoing to dn8ure re3ident care
plans reflect thelr oare needs.

SSrE
5

Lc

(2)

oversee develgpmenl 9f s wrltten plar of care for
eecn re$ident that a6 based cn abi$tie+ snd needs
as benlilred in the rasident a8se$sm€nt. Aplan
d care must describe lhe care aild services
nsc€$sery lo assist the rssidenl to malnlain
independenoe and well"being;

3,

resldenfs carF nqeds.

Thi$ REOUIREMENT is not met as evidenced
STA1E FORM

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tuJMtl

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 '10/31/2018 Wss l5t

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$MiMARY STA1FMENT OF O€FICIENCIES

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Continued From page

F

t0rmr20{8

s, 91,st6

0149

I

b!,
8-aaed on lnlervlew end ricord rcvisw, the RN
(Regbtered Nurss) fail€d to devehp wrltlBn €re
ptens to addrsst eech reoldenfs ldenilfied ne€ds,
to tulclude measurable goel$ and specltic
lnterventlonE to addrcsr tholl nccd9. ln addttlon,
nurslng stalt tailed tD conelstently lmpl€mBnt the
residcnt's care plan lnterventiom lor dally tlare
and soMces based on a reviaw of care gists'
docurnentdd dally calE. Theee prac.tices affected
3 of S reeldcntE ln th€ eppilceble sempls.
(Resldents tr l, 3 and 4). Flndlngs includa:

PRO/ DER€ PrAr,r Ot 60nnecrnx
IEACIH f,ONRECTIVE ACTION EHOULO BE

-

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PRGFIX
?,\O

R146

ctiogg. iEF gRtt{cEo

{x6t
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to tHE A/PRopRIATE
DEFICEilCYI

0A16

conllnued from page 7

4,
5,

6.

Education on wrltton care plans
be oonducted for all nurses to
6n$ure residsnt'e tresds aro mat,
The Direotor of Nurelng wlll
for compliance.
Complianee will be sompleted by
Novcmber 3, 20'l8

1 . Per rccofd revi€w on I 0ll/18, Resldent #1's
care plan fallcd to addroes the rerldents
behsvior& related to romoulng mcontlnent briets
and pulting tlrem in varioue areas wllhin the
apanrnent including on fumitura, in closste and
oh the floor, ThE nur6€e w€ro ewsto ol a urhe
odor ln this room yet failod to dsvelop a
comprehensive plan to maflage this Feue and
asstrre $rat the resldent 's care plan met the
resident's needs regerding incontinence
concrems. The care plan stated to toiletewry 2
hourg, hsrvever therg ia no cvidcrtcc of rocsnt
assotsmcnt to ldehtlfy why the odor was
pery83lve, not t0 change the plan to see ll more
trequent toilellng helped to manoge the issue.

h

!
F

ot the card plan mrrilng nol6s wlth
the family dated Aprll 25, 2018, it hign$ghlad
"loenalls" 8s needrs tg be done {tlled and
trimrned) and lhe lamily rdquested weekly
showere be ineresssd ltom 2 timeE ws€ldy t0 3
tirnea workly. Far rgvlerv of the cfilB glver
doeumentdtlon shcet . the Mey shcaE eEld
chowers 3 tim63 per vveek hut the June sfld July
$he€t$ sald showers 2 times weekly, with many
missed showers noted. Toileting every 2 hours
wae documentgd as flol done on 2 days lor JunS'
Per revlew

SIATEFORM

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flAME OF PROVIOER OR *,IFPUER

STRSE?AoDFESS,

PiLLSBURY MAI{OR . SOUTH

20 HARBOR VIEW ROAO
$ouTH EURUN€TON. W 0540t

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CROSS.REFC RENCEO TO TI'€ APPROFFIATE

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il wag not doanmented Bs done on 5 dayc during
Juty. Rpg*ditg nsllcars, tht aheat dated to flle
and trln nalls 6llet each dhowori dudng June, it
urss documented as done 3 tlmes htgt during
July it wss documented ss don€ 2 Umss only,
During intervistvw{th Fesident #1's lamily
member on 9/30118, s/he staled thal lhe
resldenl'r 19sq9ils were conElEtenlly very l0ng
and cuded anr he top of the toes. s/he stat€d
that ihey the hsd brought up the lack ol toenail

care and kimming m multiple occasions
{lncluding 6t the last oere plan rneeting on_
4r25l1S) to trcllltt nurges vrlthout re8ult8, Th6
fsmlly had slso feqrcsted lhat ll1€ fsclllty flnd 8n
approprlate cleanlng produel to hBlp elifilnate the
nefvalive urlne odor ln the resident'g roorn and
irallway ereas. This was not sehleved per the
famlly
2. Fer recotd teview, Rasidefit #3's care plan to
addregg felle *Bt€d that lhs r€sideflt wed fiot a
hlgh fail rish, However, revisw of the te*ldent's
fpils since 8/1t18 Bho\ €d 4 fallr between 8131/18
snd gll A/1 8. The bFt cHre plan reviaw qsg daled
4/1/18, and stated lhat lbe resident had 6 falls in
the previous 60 days. As of 10/118, there were no
r€c€nt updgt€g, new lnt€rv€ntignt 0t 6valudtion3
rcgardln$ fallE ln the racord, A numlng nota of
S/1 Sr18 alter the res'ident w8$ lound 0n the floor
staled "reminded resklenl about ltre call pendent"
and lha resident rePlied thal fE 'forgot about that.'
The residenl had put himeell ofl tlre floor and
crawled to ttre bathroom because he did not wani
to hlli thorE \^r€s no nuralng evaluetlon of thlr
change regarding mobility, (The re$ldent wat also
legally ullnd due io macular degensratlon end
glaucoffia). The care plen also failed to eddress
the residents needs rel€tgd to constlpation and
admisiion to Hotpico Services 0n 9/22118.

STATE FORT'

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PnOvlOERr€UPP\lER/CU/a

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IOENTIF]CATION NUTilBER:

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IEACH OEFICENCY fiTTJ€T BE PRECgDEO SY FT'LL

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10 flARBOR VIEW ROAD
SOUTH FURLINOTON, VT 0640I

PILLSBURY ttlAtt0R - SOUTl"l

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DATg

8?REEIA0DReSS, 911v. 3rArE, llP co0E

TiIAME OF PAOVIOEfi OR 9IIPPLIGR

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IDENTIIYING lNFoRilArloN)

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FnOVIBER'& PtAl'l oF CORRECTnil
IEAOH CORREETIVE ACTIOH SI{OUIO BS

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Per record review, Resident #4'a care plan
regarding th€ rlBk of tslls plan was l6st tcvlewed
orizttetia, Durlrtg thc pe'ttoo frotn 8/1/10 to
1011/18, tlre tEsldent hcd S falls, lncluding 2 fallr
wllh filnor heed iniurie+, There was noevidence
of any evEluation, reasFgg8menl 9r new
interventions aller the 5 recenl t6lts. This resldenl
was Elso reoeiving anticoagulant th€rspy, whioh
mskes the rbk of bleeding due to lnJwy greater,
The care plan did not dddr€es th€ resfdenfe uss
of dally H6od thlnnsre . The reeld€nt was also
bsing ircatad with mEdlcatlon for depr€sclon and
tho Care plan dld nol include any nulslng

3.

lnterventlont rdEtod to motiltoring fol
offgctlvcne8s and poseible 8dv6rce side 6lf€ctB.
6nd did not inotude any supportlve interventisns
by alaff.
The above findings for thd 3 le€ldents wsre
conflrmed durlng lntervlow wlth lho DNS on

ll

10/3118.
R1

V, RES1D€NT CAREANB IJOME SENUCE$

RlS0

SSrO

5,9,c (7)
Aarur€ that eymptoms or eigns ol illnese or
uccldent arc recorded al lhe time 0f occirtrenc€,
slong wllh Fcuon lsken;
This REQUIREMENT is not mel as evidenc€d

Rosdiont #1 no longer resdies in
the faclllty
: . Rsvlew blcurrenl residents with
nursing slaff and lecord revlew
will be conducted to onsure
residont care needg sre met
3. Eduoatlon of nursing slaff will
include appropdnte
communioation and

u

documentation of residenUfamllY

by:
g'aspd on stall lnterview and record revlsw,
tscilitv nrrsos feilcd h documont follow up gHre
and nbtittcatton to the PCP of chang6s in lssifl$nt
condttion/symptom* in a timely manner on two
occaslons for 1 ol 4 rasidentE in thE sample.
(Resident#1). Flndings include;

8TATE FORM

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FORMAPPROVED
STATEMeilT OF PllGJ;NglEt
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continued From page

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'O
souTH

€lrMtvlAfiy STATEM: {T oF 0EFlclgt{0 €g
.IEACH
DEFICIEHCY MUST Bg PRECEOdgl 8Y TULL
dCCUUTONV OR L 3C IDENTIFVING INFORMATON}

(x{) r0
PRGFIX

Cttv, sTAlE, llp

IIARBQR VIEW ROAD

PILLSBURY UAI'IOF . SOUTH

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CORR€CTION

iE^CN CORnECllv! ACfloN SttouLo BE
CROSSfiEFEFENCCO TO ThE APPROPRIATE
0EFlcrEl,lcY)

sontinuEd from page

coif,t€lE
OATE

t0

willbe oonducted b]l
ahlft report and nurslng Progtsss
notes weokly x 4, then monthly x

4, Audlle

1.

Per record reviEr'tr. the nurge failed t0
document lollor^, up aetlon$ in the fiedlcsl rscord
lor Resident #1 eller lhe resident complpined ot
right rib area pain and coughing wilh white
pfitegm production 0n 8r28/18. There wag also no
note stath0 that the fsmily and the PCP had been
nolified of the resolution of the residenl's change
in rymptoms.

and ongoing,
5. The Direslorf Nursing or

wlll monltor for cofipliance.
6. Compliance will be complot€d bY
November 3, 20tB

Per racdrd review. lh8 nurse feiled lo noti[t lhe
PCP after diecharge instructlons from an Urgent
CarE Vi*lt on 0/5/18 ttated lo "Call the PCP offlce
lrnmedlsbly lf you arc havlng any vomltlng,
diarrhca or worsenlng eymptorn$ bctors Monday"
(9/10n8). A nurslng progfess note datod 9/SrlB
ai 11:52 AM, atated the resldcnt uas incontinenl
of a lerge emount d semi-loosa etogl, The nurse
dld not-acr on he discharge inetuciions given by
ths Urgsflt Care Center provkler on 9/5/18 to
notlfy thg PCP lmrnedlately,
These fallutgs of nur+as lo follow up afler

2.

changes in resident condition were conlirmed
wllh tlre ONS during lntervlew on 1$/31/18.
V. RESIT]ENT CARE AND HOME SERVICES

ft206

SS.D
5 17 Dealh ofa Residenl

5.'!7,c Wh6n a rEsldeill diec unexpoctedly or
witlrin 48 hourcof I tall or injury, n addition lo
notlfying the medical extminer, the licenses shall
send a repon to the licensing ageney with the
lollowing inforrnation;
t1) Name ol residenl;
{2} circumstsnces af lh9 d6eth;
(3) Circumstances of any recent injuries or lalls;
STATFFORM

tat9

1, The resdient no longer rsedies
ln the facillty.
2. Education of nursing staff
rogarding regulatory
requiremente surrounding
unexpected death will be
conducted to ensure
regulatory complianco
3. Thc Dlrcctor of Nursing or
designee will monitor all
aceidents/deaths

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SUMT\,IMY STAIEMEilT OF OEFICIE'{CIE$
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RE€UIATORY OR LSC IOENTIFYII{F INFORfVATION)

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R205 continuBd Ffom pag6

c
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10 HAREOR VIE\I' ROAD
SOUTH BURLINBTON, vT OS{03

MAilOR. SOUTH

PC€FU

SURVEY

STREETADOREaE. C'TT, 3TATE, AP COOE

tlAMEOF PRO$OER 06 EWPTI€F

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PROVI0ER'S Pt.Ail 0F C9RneC?GN
{EACH CORRECTTVE lc?loil EHou$ AE
OPRIAf E
CROOS,RI FEIENCED TO ?Xg

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gontinued from page

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(4) A ilst of all medlcoliond and treatm€ntE
received by he resident during ths two (2) weeks
prior to the death.

4, The Direotor of Nursing
wlll monitor for complienca,

This REOUIREfIIENT is not met as eVidenced

5, Compliance willbe

by:

Based on slaf{ lnterview and record review, lhe
laclllly feiled to report an unEltpecled reeldent
dea$r of e rasidanl who diad es E €sult ol lttjuties
Eu8talned durlng a fdlat he fadllry, (Reeident #2)
Flndhgs inelud6:

aompleted and effective

this date, October 26. 2018

Per review ol the medical recold efid a death
report from he Oflioe of the ahief Msdlcal
Examiner, Rasidentf2 experienced ? falls on
9/1118, ons at 10;30 AM and one at 4 PM, Ther€
r.r6re no obvlous lnfurles and no paln roported
lrom the lirst lsU et 10:30 AM. For the 4 PM fall,
per ttre progress note, lhe rosident was found
lying on the floor in their room with the head
igainst the wnlUbsseboard heater, The resident
complakred of pein in lfte back snd then the neck
afea. Th€ resldsnt wa8 s€nt vla 911 to lhi ECI l0r
evalualion, where ethe u€c dlagnosed wMl
oervicol spine fiaclutes and pulmonary edema
and was adnritted. The residenl died as a r€eult
0f th€ iniuriBs on 914118. P6r levlew ol he deeth
c€rtllhats report from thE Orice ol lh€ ChiBl
MadlcalExamlnedg Ollice, the death wEs rulcd
accidentaldue lo ifilt fles lncluding multiple
cgrvicel spine traotures Bnd a smdll epldutal
hetnatorna at tha carvical level, as a resull ol a
hlr.
The facility failed to report tha unoxpcctcd dealh
due lo hjlrfio$ sustalned dudng a fEll h the
Limnstng Agenoy. The failure to report the
unaxpected death wss confirmed during
int€rvi€ws $'ith hs Dhector of Nutges (0N8) and
Nurso on the afternoon of 10/2/18
the
STATE FORM

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gUilI\IARY STATEMEI.IT OF OEFICIEHCIES
IEACH OEFICIENCYMU$T 6E FRECEOEO BY FUtt
ire uuTonv oR Lsc tDENTTFYtNG tNFot{\tATlotl)

R223 VI,.RESIDENTS' RIGHTS

05403

pnoqDE*$

ID

PR€FIX
TAG

R223

SBrF

6.11 The rssldent has the rlght to review lhe
r€tidenls {fiedlcgl or tingn€ial r€colds upon
requ6sl

FLAr^l

0t coiREenoil

(gAcH coRR€CTtve ACTIoN SHOULD 8E
CROSS.REFERFN9EO TO THE AFPffOPHATE

fi61
COMPTETE
OA?E

oERClEilcY)

Ths corBorStB team has hcon conBcted
email on pg1659r 28 20lB ss wellag lgday,
Oclober 31.1018. As of today, I hdve not
r€c€ivcd a responBe regarding this

Thip REQUIREMENT ls not met a3 evldenced
by'
Bbsed on interview and record revieyt, lhe facility
hag lalled lo asgure thal eash resldgttl hqs lhe
rlght to revietrl ther finaneiel reoordg upon..
request and lhat cunsnt residentr had slalt
avaihble for assisting wlth thls right. This paciice
has tho pobntialto affect all reeldentg of lhe
focility, Findlnge include:

Fer informatron recelved from residenle of the
faoility, the facility licensee has failed ts assure

acceia to lhe financial records ol eech resident.
As of he eohpaint eurvcy complsted on 10/3/18,
the faclllty had continupd to fail to lullil thE lams
ol the resld€nt tdmisslon agreementa by faillng to
bill for thsir rnonthly rsnt afld E€rvico$' Duri*g
interview wth a reeldent wl')o wished fd b€
anonymous on 10t?10, $/he was v€ry digfesEed
at the lack of bills received; #he said the last
monlhly bill reneived wae for lhc month of March;
201S. Purlng inhtvldw, the only buBln6B$ otllcs
ernployee availablc for tho f€cllity slaled on
10/3116 lhat sthe dld not hsve any tnl0rmatio0
regarding resident billing ptacticestpr0ces$e$.
Sfre etet€d thal the employee who used to
ov€18€c lhlt aroa had reaigncd the prevloue
week and thcro w68 fio replacemant slaff
available to facilltata t revelv of financigl fecofdg
if any resideni of $re lacility withed to revie\i,
lhess records.
STATS TORM

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VII. NUTRITION ANT} FOOb SERVICES

W o6{ot
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OF C9RnECTIOI{
FROVIQEflIS
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CdOSS.REFERENCED YO T}G AfFROPRIATE

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R238

SS=C

1. There wer€ no resld€nts sffectsd

7.1.a. {7) The hwne shell maintiin auffidient food
*upplies et hand sn the pramirea to mcet lhE
requirements 0f lhe plannad weekly ri6nui,

due to the potential of unavaile
foods at the faclllty
2. A deily meellng with fre FSD and
Acling ExEcutive Dlrector now

Thls REQUIRSMENT lE not met s$ evldale€d

occure to revlau, food euPPlY

by:
B-ased on observatign and stall anteryieWs, lhe
fociltty failed to mnintain sufficient food eupplies

3. The F$D will monltor vendor
payments for llmelinees,
4. The Acting Executlve Direc.tor will
report to cooperate oflice and the
Accounta FaYable dePariment for

at hand on tha prernises to rneel the
r€qulrementB of the planned weekly menus. The
lack of sornc menu itcms had th€ potential to
atfect all resldante ol the taclllty. Flndln$a lnclude;
PEr ohNervauons in the l(ltchen at l0dllty on
10t1118, several 1/2 gallon contsiners of mllk
wem in a plattlc'bus'tub; the F$D confirmed that
they were to be brought to lheir adiacent facility,
Allenwood, becauce they had 'run out of mik thir
rnornlng' , On 108/18 at 10:40, duling lnlsrvl€w
the F$0, whg covels both Allenwocct snd
Pillsbury Soulh, slhe staied lhat s/he had
recelveit a lew'hunored dsllare'lrom the busines*
oflice,'s pEl(y 6a6h eccount to,purchase bread,
Julce and oggr for boh f$cillllft (Allenwood and
Plllsbury Soulh). TIte FSD stated that m0ny
vendors wete not deliveilng foods vvhen ordered
due ts a lach of tirnely payrnent and that he may
hav€ to start using he emergenoy lood euppllee
lrom the freezers lf things dldn't get better 3o0n,

.*l

SS=F

IX. PHYSICAL PLANT

5.

Peyrnente to be completed uPon
recelpt.
Corproarte complionce on timely
paymenta willbe immediato re of
thl$ date, October 26,2A18

R266

I

9.1 Envlro{Tnent
9.1.s The hsme must provide and maintain s
safo, functlonal. sanltary, horns[ke and
FTAIE FOR[,

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 't0/31/2018

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SOUTH BURLIHGTOH. W 06403
ZO

SUT'WARY SIAf EMEHT OF QEFIGIENOIES
8E FRECEDEO 8Y FULL
{ETCH DEFICIENCY
lDENrlFtlNs INFORMATION)
R6GUTA1ORYOR L6d
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CROSS.REFERENCEO TO lHE APPROPFIAT€

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R268

R266 Continued From page 14

fl{

coirFlErE

ccntinued fsrm page 14

comfortabh environmenl.

2.
Thle REAUIREMENT is nol mel

at evldancsd

by:
BbsEd on obeervatlon, ths facllity failed to provHe
a Oanilary and homcllkl srrvironmlnt in all
reeident areEs o[ lha bulldltrg on ths 3 days ol
survay t10/1/10 - 10/8/18,) Thls complalnt hEd ths
potentlal lo sftect many r€sldenl$ residlng on lhc
affEcted unlts and arry vlshore 0n lha 2 unlts
ldent{lled, Flndlnge lnclude:

Ba$ed on observation3 of fie 1et afld zfit ffoor
sa$t wing resident units on ihe afternoon of
10/1/18,lhe lollowing wm noled: both *re firsL
floor and s€cond lloor eesl wings wera noted to
htve ollenalvg uilne odorB; however, lln aemnd
flnnr RaRt trnll wnn vnry nlron0 find fiFlvAniLl thF
entire length ot th€ hallway, witlt 2 er€as on lhc
halhrray with especially $trsng utine odots. Tho
caneted flooring war also worn and had a rfilsod
ridge near the end of the hallway, near lhe
eecond floor elevator; lhis presented a polential
tripping hazard. Although the facility slated lhd
the carpBted floors had baen cleaned, tha
objectionable odol remalngd slrong in tllat aast
seoond frobr area dudng lhe dates of lhe survey.
The pervasivc odore and wom state of the
c€rpel6 wae cnntkmed during a tour ol the areas
wilh the Dlmctor ol Malntcnance on the aftcrnoon

The Dlreotor of MalntenEnce
or designee will develop a
rcheudle for all carPete'to ba
cleaned on a regulsr ba$b,
3. In areae of dirrepair or inabillty
to remove offansivo odors,
carpets will be replaced.
4, The Diregtot of Malntenance sr
designee will monitor the
environment during waekly
rounds
Compllance willbe oompleted

5.

by December 15,2018 or
earlier

ol 10f1/18,

STATE FORM

3uJ$rt I

lros{lnusilm rneet tE of   3

 /''\.LYERMONT

Acsxcv or l{uvrex Ssxvrcps

Dnpe*"rms,NT oF Dlsestr-rrtns, Acrruc lNo fxoupnNDnN'r Lrvruc
Division of Licensino and Prolection
HC 2 South, 280 State Drive
Waterbury, VT 05671-2060
h ttp :llwww.dai l.vermont.gov
Survey and Certificalion VoiceffTY {802) 241-0480
Survey and Certification Fax (802) 241-0343
Survey and Certification Reporting Line: {888) 700-5330
To Report Adult Abuse: i800) 564-1612

October 1,2018

Ms, Barbara Moynan, Manager
Allenwood Al Filtsbury Manor
90 Allen Road
South Burlington, VT 05403-7856

Dear Ms. Moynan:
Enclosed is a copy of your acceptable plans of correction for the survey conducted on
August 15, 2018. Please post this document in a prominent place in your faeility.

We may follow-up to verify that substantialcomptiance has been achieved and maintained. lf
we find that your facility has failed to achieve or rnaintain substantial compliance, remedies
may be imposed.
Sincerely,

Pamela M. Cota, RN
Licensing Chief

Disability and Aging Services
Llcensing and Protection

Blind and visually Imparied
Vocational Rehabllitatlon

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An unannouncqd en-Jls survey wsg completed
on 8115118 by the Vermont Divlslon of Llcannlng .
and Plotocllon, Ths purpose of the survey wae to
ioveslilple t\ilo mmplaintE rsgarding te6lrlenl
car6 and sarvlcos. the loliowlng rogulalory
violailon6 were loenlllled.

RlO{ V, RE$IDEN' CARE ANO IIOME SETTVIoES

Revised

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$ee Attached

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5.1 Admission

a

5.2
Ptio( t0 or al the llrna oi edrnlsslon, 6ach
residenl, and tha f€sidenf0 legal reprcsentallvo lf
any, slrall bu provlcted wlth a wrllt€n admlgslon
agroerncnt whioh dascrib€a th€ dtsily. weekly, ol
nrnlhly rqto to bE charged, o doeoiiplion ol lhe
aarylcet thot At6 covsrad ln lh'e rato, and ell olhor
oppllcalda financlal i$suos, lncludlng an
orplanallon of lhe horne'e pollcy rog6rdlng
cllrchargo qr transfsr whan a regldenl'e flnancial
rtatus changor from prlvalely paylng io paylng

with SSI orA€C$ 5u6sfllg, Thle adiliission
sgrostnent shall speclfy al lsasl how lhe lolladng
ssrvlces wlll ba provlded, and what ddditlonst
cnsrges there wlllbo. il any: all porsonal care
aervlees, nurshg ssrvicos: mgdiaallon
managernent; loundry; transportotlon; toilotrias;
and any $ddltional tervioes ptovidcd undsr ACCS
or a Medicald Waivor program. ll appllcable, the
agreement musl sfJecify lhs amounl snd pulpose
ol ony doposit This agreemont rnuel aleo epeclly
the reslqent'$ lronster snd dlschargo flghts,
lncluding provleions lor tufunds, gnd tnusl lncludg
a des:ripllol of lho home's porsonol neods
allowanco policy"
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NAME OF PROVIO€N 08,SUFPLIEA

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$OUTI.J FURLINGTON, VT 05403

SUMlvlArlY STATEMENI OF DEFlClENOltg
(EACH OEFICIENCY MUS1 b6.PNECEOED EY FUIL

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shall,ncludo; .ih6

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ACC$ service$, the gp€cific room and boald rate,
the.6rnount al pef$onalneeds allowafioe and ths
providg_r's adrsernBnl t0 eocept room 8nd board
anrJ Medlcaid 6e gole Paymenl
Thlg R€QUIREMFNT is nol met aB €vldohcsd
by;

Baeed on staff lrrtsrviow and record fovievv, 15a
facllity frlled to provide an admission agreement
that explgln6d lo the reEidenVlegal tgpresentatlve
whot execl serviceg werE lncluded ln the 3 stated

"$tages qf Carc", #1, Exlra Care, #2. Slaga l,.and

f3. Slage ll, Resident #2 was sdrnlltsd to the

Re$idofttlal C€re Horne.and based on revlew of
lhe ?,woek sdmleelon asoes$ment, tho rosldent
did nol nreet the crltefla lol $tage ll yet the
signed admission agreement documented thal
lhe resldent was to be billed for cHre ahd
per$onal $ervlces Ht lhe $tgge ll lcv€l. Findlngs
includp;
Per revlew ol Reslderil lR'o ndmisslofi sgrgsrnent i
provlclad by lhe Co-Eiecutlv* nheQtor on 8i'l4llB,
tho $,brding used'to describe each elego of carq I

wfis not specllic, Th€ 9t€gs$ of Care were
doocrlbod as followsi
"Extta Care - reeldent raquiros slandby
asqistance up lo or inoludilg m6dlcati0n
management snd sftbulatlon. Cost - $750.00."
"$tage l- rcsldent requlres care beyond th€ Exlrs
Csre slaoe whlch qay lnclude moro in-depth
asglslanue wilh ADLs, hygiene naeds,
anbulaiion, per$onal care and increaeod
involvemenlwlth llle reeidenl'$ physlc,an, Cost $1,000,00"
".$iage 1l " resident roqulres ear€ beydnd &lege I
whlch MAY lnclude regulsr mfety ehecks, dlracl
lnvolvernonl wlth AQL functioning, cu6ing end/or
STATE FORM

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A, BUILOING:

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0172

STfiEET.AODRE$8i

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NAME OF

'IR$VIDER

ALLENWOOD AT PILLSBURY MANOR

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SOUTH BURLINGTON,
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OFO$$,NETER6NOE6 T9 TI.'EAPPRgFRIA'I

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OEFICIEHCY}

R104 Coililnucd Fronr pago

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Rl04

rsorisntlng, blacJder/bowel insontinence
manageotenl and lnofeased involvement wilh the
r€dldsnlrs physlclen. Cosl - $2,000,00 per month
ln addltlon t6 bags f€nt."

l'he admlsslort agreem€nt sta.ted thal "6ll
residenls und6rg0 an lnitial 2 waek ass€Esment
by lhe nursing team alAllBnwoCId. Aftst lhi$ e
waek Ass:essmenl fr6riod, lhe hur$g manager,
resldenl, and lamily w{ll agroe'lo a pl6n of
regldent cere 6ervlce$ which moy includ€ some ot
allol[ho llsme lloled, As lhe residanl's nsedg
. ch8ngo, Snotheraegeggrnent srid sdJuslntent ln
t€sidentiel carg seMoes fnay b€ nocessary,"
Por review of the ReSiclent Admlsslon
A*gessmont datecl 6lt 1/1 {t, the resldenl wao' lutly
cognltlvely lnlool (alorl and orlanted) Bnd wa€
independont vrith slld€clslor maklng, The
rcoldenl w€s corlod as indspsndanl ln physical
funclloning (ADLs lactivltles ol dally llvlng],
lrrolrrdkrg moblll(y, atnbulallon, pgrB0nal cBre,
tolleting, lrygleno and hathlng), The residentrras
corlllnqnt of both bladder and bowel, Ths rssident
hAd roc€nt $urgery and reqvhed paln
mgnago*]ant and monllodng of a hosled surylcal
wound Fy nu16os. The fe$Hent wa$ q65€Fsed tor
the highest ievcl of qare, $l*ge ll for lhe en{lra 4
week stay,.stthougft lhere wag n0 €vld€nce that
levol 0f care l,v€i need8d,
During intefvlow.0n E/'15/18 ot 3:30 PM, the
Liconsed Prectlcgl Nurse (LPN) who completed
tho 14 day admi$Blon B6setsrn€nl atated s/he
dld not kndw $Jhy th6 resident was assigned
Stage ll level ol care tlased on the odrnisslon
6$nggsrnent. S/ho elated th6l th6 residsnt
rocoivad medicatlon administralion, Ths LpN
oonfirmgd that 6lhe had nol re"assosscd lhe
resldsnt's needs stter lhe lnillal 2 weeke ln the
gTAT,F, TORM

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NAMF f,F PNOVIOEft OR SUfFLIER

ALLINWOON AT FILLSAURY MANOR

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aw1Bt2018
91 RG,€TAOORES$, CITY. TTATE. 7IP {:OOE

90 ATLEN ROAD

$OUTH SURL[,IS1"ON'

SUMMAnY STATCMeNT or oEP.lcleNcle$
{EACH oet?tctENcy MUST Bf m€cEDEo 8Y FUI,L
R€gUr ToRY OR Lsc lSENIlFVltt,fi lNFORuATlOl{}

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R104 ContlnUod Frorn page 3

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VT

05,403
PROUOER'S Ft^N CIF OORRECYION
(EACH COnneCTtVE ACTTON SHOULT' 6E
CRO$S'HGTGNE,NCGO TO 1IIG APPROPRI^Tg

(x6i
00Mp{EtE
OATE

Dqflfl6NcYl

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faclllty. Per roview ot th6 progress nolss and
medlcallon edmini$tratlon rocords, lhe nur*aa .
had provld€d peln q66g6ry1snt, monllorlng of
iho surgical slle and lnvolvomont wlth lhs
physician lor medipatlon ord€r6 slnca admip*lon,
Durlng inlsrvlew with lhe Co.Ereculive Director
on the afternoon ol 8/1 S/1 0, $/h6 could not
doscrlbe thB spaoltlc dlfi€rencei lor th€ 3 St0gos
ol Cars slaled in lhe adnrisslsn agrsemonls and
what tha chargos wera bessd on. S/hs alsg
gontlrmed that there was n0 oxl€ling wrltten
. policy/procedure 1o descrlbe the $tages of Oalu,
{llefer also lo R ?00}.
R129 V, RE$IOENT CARE AND HOME gERV1OES

Rl?S

li$sl)

5,5 Qeneral Care
5.6.a Upon a residenl's admission to a
reridenllal caro home, n€ceB$ary eervissr ehall
be providod ot snanged lo rneet the reeldsnls
p0l50ndl, prychosocial. nursing and medlcal care

I

needs.

Thls REOUIREMENT is nol rnqtes evldeneod
by:

Fased on staff lnterview and rscurd rcvinw, thB
taclllty lailed to provide the neeessary servicos lo
meot each ro$ident's nur$lng ancl nodical needs
lor 1 a{ 4 applicable re6id60lp ln the $Brxp,e,
{Residenl #1), Findings lnclude:
Per record review on W 4J18, Resident #1 war al
riek lor bowel compllcations, lnc[xJing
oonctipslion, and licensed nurses faikrd to

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rOlir,lTlli ICATION NUMDER:

Ol pnovloEn llR gllPPl.l[R

ALLEI(WOOD AT PILLSBURY MANOR

90 ALLEN NOAD
EOU1H BURr..t!'t(iTON,
tn

pnFcE*.R0 SYFULL
{tASt{ 0ErtCrE}tcv Musr 8E
ieout^TolrY oR L$6 IOENTIFYINB lNFOnl{Arlolll

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6UMM^RY STATEMENT OF OEIIC}ENCIES

(x{) t0
PFEFIX

Col,rFLITEo

A. BUILOINO:

B, WNG

a372
NAME

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06403
PFGVI0ER'5 P$t'l,Or CORiECTION
{C^CH COFRECTIVEI\ClIQN SHOULO 3C
CRO$$REF€q[{CqO TO'I} IE APFNOPSIATE

{x6j

noMil,6r6
bAY€

pEfl0lENcY)

-

provlde keatnunl until lhe surueyol hrought lo
their ailenuon that trcaun6nt rjocumgntallon
showed the reoldent hod gone for 10 days witholtt
e bowpl movemen{, The rsgldsnt w?s roceivirq
Hosploo gprvices end frequenl routlne and PRN
(as ns€dedi dosss ol Morphhs to manago psln
{morphine is knorvn to conlrlbute to consllpatlon).
ihe reeldent was dla6nosed with lnlerrnltteni
recl'alprolopse and had phycisian orders to
rnonilor bowel rnovamonls and lor lrealment to
reduce lhe rc*tal prolap$B a$ ne€d6d. Per rpview
0f thB MAR (rnedication admhlstreilorl racordll0r
Auguel, 2018, there was ne documonted bowel
rnovsmdnt {BM) from 8lAl18 - 8114/18. fh€
resldeni had ordsrs fot Miralsx 17 grn. eve4t dey
and nurses aod MT {msdlcailon tecltntcibns}
docurnentod reftFal of tho Mllaldx fronr 811/18 lb
8113119. Fet intervlew on Bl14/18 el 3 PM, tht
ovenlng shlft LPN war asked why ihe resldentdld
not rBcghs. qny rfisdlsation to all€Viate ihe
conotipation bnd laek of eny bowel movement
sinco 81311€, The LPN slated tnal lhere wss &n
order for Colao'o {a stool sof terier}; lrowever the
rosldent was no longer tsking pO medleationp,
$lre had nol asked tha phainuoy gbout llquld
Oolace allhough tho rosld€nt was able lo lai(s
liquld medlcalions. Ths togldent also had Hospico
ordsls lur Bisacodyl, '10 mg, supposllory PR lor
c0nstipetion. ln respanse lo why the rosldsnl was
nol glven e supposltory, the IPN siated that s/he
couldn'l adnrinialat' that rnsdtcatlorr due ts lhe
tectal prolapse {o0 rnlorrnitlenl iesue). The
\
Dlrector of Nu$6s was al$o prosenl for
interiew €nd italad lhat thE Bilpposltory could he
given d{ter redustton ol tha prolapss rectum if

lhe

needed.

A{tgr the conver$atlon lhe LPN dld an
ass€ssrnonl of the rqsident's ebdornen and
adminlsterad tho Blsacodyl PF end lhe resldenl
subssquently had s bow€l fir)vement ltster iho
5TATE FORM

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(EACH DEIiICIENCY MUST BE pneQEnEO 8Y
REQUTATORY Ot L8C loetlTlrYtfid

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CONSTRUCTION

A, BUILOING:

VT 06403
tSOVPEB'$ Ptrl{ Or COnRFfiTlOltl
IEACH CO.nRESTIVE AC?ION $H0utjo sE
CRO$$-FEFEFEH0GD T0.THEAPFROPRIATE
DEFISIFNOY}

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OqMNTETG

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R1?6 Contlnried From psge S

R{?S

$am6 day. Regardlng managemenl of a
re$ldent's bowel functlonlng, the evsning 6hlft
LPN slelod lhEt they do Bdmini6lsr laxallvoe snd

stool sotlsnors on the evenlng shln; 6ny r€sldbnt
with 3 days of no SM, v/ould be g{vsn tnsdl0ali6n
to faoilltatg I bowo! movQmenl durlno thB Evsnlng
$hln,
Per review of the carc plan, lhe plan lor the rectal
prolapw was ldenl,lfled and lnterventions lncluded
mgnlioring pf bowel movornoflte,.A physieiHh
arder datod 2116/18 statod: ?pply grahulated

uugario rectsl prolspse ae negded lo reduco
tsonlaot RN.at MD ofllc6 for l0rlhor inslruclions'),
The prcsende of lho rsctalprolapse lntermittonliy
had lha polenilsllo compllcate lhle ratHent's
dsks rlBted tq c0n$Upafion, The care plan dld nol
pddrag* lhe nspd fuf on,gshg nurEs manltoring
ol lhe rsclel araa and redrrctlon of the prolapea
whon il ocnurrsd..
Refet also Io R 1415,
R144 V.IIE$IOENT CAREAND HOME SENVICES

R1{d

$8"D

S.9.c,{ 1}

Cornplote an ss.gessnlsnt ol lhe'resident ln
accordsnc€ wiUl .sectlon 5.7:

,fi4'ffi

Thls REOUIREMEN] is nol mat as evldonced

rt

byl

Bgsed on $t?tf Int€rview afld recofd rsviow, lhe
RN failed lo completed &e adrnlssion
asse6Enl6nl wlthln 1{ dayS cl adnission ts the
facilily lor 1 of 4 residents ln lhe appllcablo
$arnplB, (Rsslderll # ?), Flndinos lncltrde:
Per revigw of lho Btate requhed admleslon
STATE TORM

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llconlinuation Etrdot 6ol

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NAUE OF

ALLENWOOD AT PILLSBURV MANOR

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SUMMARY $TAI EMFNT QF Dl:"FlClENClES
{EAoH OErICISNCY MUST 0F PffSCEpED 0Y
nEG{JIATORY OR t"8o lDFl{rlFYtNO IiIFOOMATION}

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OORRECIION txtlt
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{€AcH sonREoTtv5 Acll0N $Houlo

CROSS'R€reFENCEdTO?HE"{FPnoFRlAlE o^fd
DEFIC cHCY)

R141

assossncnt, Fesidenl ll2 wa$ admittgd lo lhe
faqillly on 0/21/18. Tha assessmenl did not have
'lhs
the requlred slgnetu.B of
RN to dsnot€ thsl
th€ fiN had rsvlewsd ths 6s6esgmont and egr€ed
wllh the ass€ssm&nt ag wtlten end lhel ths
basomenl wos compl€ti, The inc*npleie, lale
astsssrnenl wss eontlrhod during inteliutrl wilh
lh6 LpN and RN DN$ on S115/18 st and 5:3CI Pltll

F146' V. RE$IDENT CARE A}IT] IIOME SERV1SES

-,N

R145

$$=D
5.9.c {2)
Ovatses dovslopnent of a wtittan plail ol cara for
eaoh reiidenl fhat ls baEed on ablllllog ancl needs
as idenljfisd ln ths resldent asseosrnenl. A plan
of care must doscrlbe the cgre and gervices
noce$sary to o*slst no r€sidgnt lo rnaintain
lndapondonce and well-being;

e

  t'

I

fIls

REQUTREMEN

i

ls noi rnet as avidencad

by:

Baged on ilatt irltorviaw and record rovi6w, thrt
RN lailed 10 r8visd the csie plan tc address allof
tha ldsnlified neods for 1 ol 4 applicable resldentg
ln tho rample. (Resid€nt #1) Findings in€lude:
Pet recsrd revipw and stait intorview on 8/1{/18,
Reoidenl #1 was r€ceiving Hoopice services and
was treaied wilh wilh opiode for pain
manag€rnent; opiods are known {o Dause
condllpplion errd nursing slslf lalled ts revise thn
iaeldent's qare plan i0 addless thls rraed, and
faued to addrBs$ nlonilgnng and ttductlon of a
reotal prolapse in the oarg plan. Eosed on recold
revlew, thi resldont, who had physician 6rd0rs to
s'ATE FORM

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ATLENWOOD AT FILL$BURY MANOF

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'monltol i:owel moyemgniE foi foctal prolaps0'
lalled to nave docQmanled evldenots of a bowgl
filovenrent lqr a period of 10 days, ftorn Bl4l2B'
B/14/18, when ihe surveyot lloted lhe prbblom
and AlorlBd iha licensed nurbes. The IPN for tne
shifl conllrrnod that constlpalion wafi a risk io he
monltorsd alld trealm€nl provlded for thls
resl(hnt. When aeked lf gine monitore r66ldeni
BM (bowel rnovemenls) durlng the evonlng shl{t,
lh€ nuts6 raplled 'rNol routlnely" lhen slated "l qgk
{earegivors} lf.lhere are any residents'with 5 days
Of nO bOWOI movcmgilt". Tha nur$e then repiled
the( e/he wa$ hot sirrs hqw lt rvenl.ell lhis iime
and n$ staff wole awsr€ ol the lack ol e BM for
Resldent #1. R6far alsg lo R 126,

Rl79 V, RE$IOENT CARE AND I"IOME $ERVICE$

R178

$*.E

S,l1

tI

Staff $orvic.es

5.11.a Thare shall bo suf?tcienl numb$ ot
qualllied personnal available at:9ll llmds to
provide ngces$ary Q4ld, to rnalrttain a sals and
healthy envlronnont, 8nd to sssure prorlpl,
appropriate aotlon ln c.i$ss of iniury, illneos, fre
of other enrergencios.
This REOUIREMENT ls nol mat a0 6rvid6l,rced

#M

by:

ebsed on observations, stalt lnterview.and stoff
schedule re.vi6w$, lhe {acillty talled ts provlde
adequalo lieenaed nurse staffing to enable Msd
Tochs to sdmhrlsler a conlrslled nmdicstion in
acoordancs wllh leclllty rnedication adrnittislration
polioies arld Brcc$dures, This practic* had lha
potentisl to €ffect any rae ldent who may have
requlred adirrlniolratlon ot a controlled medlcslion
rrn J weekend durlng the tlmq pp11.6 revlswed
t6/28/1€ - 8/8/'18, Flndings includel
STAT€ FORM

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NAM6 OT FROVIOFR O'1 9UPPLIER

ALLENWOOD AT P1LL38URY MANOR
(x4) lo

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FREl!IX

19

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ALLEN SOAO

SOUTH

STATEMUNI OF PEFIOIEI€IFS
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08/15lAo{8

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R170

1

Por roviBw ol the nur$ing slalf sehedules for thq
rirne pefiod of s/28/18 - SIS/18, llrare wgo no
nur6o on listed on duty on the day ahilt {S:$0 AM "
3 Plvl) on 7/5/18. Baaerj oh a complalnt received
by the licnnsing agency, an anenymsus sllogetlpn
regarding a lack of chqrg$ nur$es for ell shilte,
I presenlerl potential lssug$ wlth rogard to the

laclllty'r assursnsa ot p$mpl, appropriate aclhn
ln cao6$ of re;ident injuty, lllnoss or olhar
emergencl€s, The allegatton elleged that
Medlcetlon T€chnielans (MT) had beon assigned
aa 0harge $taff when no nur$€ wae aveilabls lo
: srotk, Pet intervlewwlth tho DNSr:n 8115118, the
roullrte stalling pattern lncludsd a eholgs nuf$E
: lrr each
ol the a $hllts dauy. ltwas notod th6t
whsn the M'Is aro adrtinistering rhedlaatlohs,
thoy could lte alryrhere wilhih a latge
snvirnnmcnt thal irtclrded 3 reaident floors and 2
. sepirate wings ol the hgme, lf therq were no
charge nurse. itle MT worjld Hlso hs rasponslhlP
fot enowellng lhe main talephone lfna altel $ PM,
altendlng io any ornergent rctidbnt neede (ouch
ac falls, inJurte$, llhg$s) ln any ol thG above
lpoation5 and edrnlnlstorlng rnadlcalions to all ol
th6 rgcidsnls ut lhe R.CH accurately and on'llm6.
The lacli ol a nur$e or: the day thift on 7/tj/18
would rnean lhat ,or any resldenl needlng
Morphina vla ortl r6uts f6r pain, ({or evsmpls,
Hosplca rosldenl), lhe Mf would not be able t0
adminlstsr the liquid FO Morphine in eccordance
with the taeJllty poticy.e{till8d. "Adminislrstlon of
PO Liquid Morphine by Med Techs", last updal€d
on 3122117, that slated:
f 1, The RN oversighl nurce will ehecl the RXcrdnr from the physlclan, snd insur€ that tlte
dal€gatBd $6d tecfi€ unqerslend the order.
#2 The RN oversight nulse wrll then pf6.draw
sny do$€S thal ars to be given by a med lech

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IDENTIFICAIIO"I NUMAUR,

0372

ATLFNWOOO AT PILLSBURY M/TNOR

fiEouueroRv on

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€O ALLEN ROAU

SAUTH BURLINGTON.

qUIVII{ARY SIAT EMENI OF OEFICIEI'ICIE9
.(EACH OEFICIENGY MUgT BE FREC6DBD BY FUI.I

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R1?B Continued From pagd

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NAME OII PITOVIDER OR SUPPLIER

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CORRECTION (x(r
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CO'tPtElU
APPFOPRIAIE )^IE

pROVlOERg PLAN OF
(EACH ?ORNECTIVE ACTIQN gIIOULO
CROtlS.REFFRENCFO 'I'O THE

.

DEFICIENCVI

R 178

Thers would not be s RN preeent to intervlew the
MI r8safdlng,ilreir understanding ol the order or
to an$wer any qusstlons that thsy mlght have"
Per lntervlew wilh the DN$, lt wp$ h/her
undsrstanding thal MTs wero followlng aR earlier
PIP lor coilrolled medications Llrat teduired lhe
MT to dla, w up tho controll4d medication'and
have a nurso oh duty chEck lhe dosa prlor lo
adminlskation to ths residgnl. Then lhe MT and

h6 nur$o woukl lh€n Bach ltlili'althe MAR
{medicallor administrati0n r€dord). Thls pollcy
lllled "MedicstionAdmlnisUalion hy unllcensgd

.

R2OO.

gs*D

slaff ' wes last revlowod en 3/Si 1 3.
tsased on tho lnt€rvlows vdth nurtlng gta{ , it wae
n6! clear whlch Pip tho Ml's wsfs roquirec, to
follow. However, ll w*s clepr lhal both
pollcle*/procedures required the presence h the
feclllty of lhe RN to asoure.that the dose was
cor.rect ae orderod by (he physicisn.

V, RESIDE.NT CARE AND HOMI SERVICHS

,d

N

R?00

5,15 trolicles and Proaddutes
Eaoh hqme musl have wrltl€n poliolB$ and
prscqduros th,et gsvern dll s€rvlcRs provide{ by
the home, A copy shall he avaliable al lhe horne
lor :evlew upot\ fequcst,

t

This REOUIREMENT is nol rnet as evidenced
by:

Basqd on statt intervlew snd lecord review, lhe
lacility failed to develop wrilten
pollolosiplocedures lo govern all scrvices
provlded by the home, related to 1 rssidon[ in lhe
npplicable sample, {Resldont #2) t'indlng in0lude:

STATE TORM

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ALIENWOOO AT PILLSSURY MANOR

90 ALLEN ROAP
SOUTH SURLINGTON,

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Fet review of a sarnBle ol adrnlsslon
agr€€monts (41, llte home failed to dsv€lop 0
wiltten pollcy/procedure to address the $tages ol
Caro as included in the reiident sdmlsslon
$gr66rn6nls currently ln use. Sae.ed on tevlow of
tha adml$sion agreentent for Resldent U.
rccenlly admllted to tho facillly, lhefe wan no
wrltten evldonce in tho medlcal record to Jtrbti$
, lhe aeeigned $tage ll level 0f cqts upon
admissioh td the home. Dqring ifitarvlow wlih ths
Co-Exoculivb Dirsolsr and the DN$ on th€
afternoon qf 0/151'l8i they co{firmod thdt lh€rc
wbs nq r#dllsn policylproc€dure for the
assignmenl of the levol of cnre for nowly admitted
resldenls al the h0me. (Reisr albo to R 104)

1.

STATE FORM

l{0t

WC}Mti

1l

qanlif1{.6lidr!

ih0el

11

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 d..:,-"VERMOhIT

Acr,Ne;v

or lft:m,lx Senvrcrs

Dr:p*,trMtcN-r oF l)rsnsu,rrrnsl lf\{+[qitr rrllllle $Utltlf {il{1P04^t1L{r1tri;1rc
H('l 2 Snutli, 28{} Statc Drivc
Watelbury VT 05671 -2060
hill/1\-{,!y,w.d,h}. vtultt'ttl"r;lov

Sut'r,ry *nd (lcrtillcation Voiceli'l'Y {8t}2} ?11 -i}480
'li: lteporl Adult Abuse : {8{}0) J64-tt-12
Survcy and Cert i licat ion Fnx {rl{t?)'24 I -0.1 4-i
S trvey an<J Cert ill<:al ion l{eporti ng Li nc:{B I li) ?00-5 3 3 0

{)atobcr

lJ

1-1.

2018

arbara \4uyr:au, l\{ nnal4er

Allenrvo*d At Pillsbury \'{anor
{)0 Alk:n lk;ad

South Burlingfon, V1' 054$-l-7836

l)ear [{s. Merynen

'lhe llivisir.rrr of l..icensirrg ancl Protcction cou:pleteil a ecmplair:l invesligaliou al your {trcility on
October 3,2018. 'l'hc prrpose ol'thc sune,y \,vas to delsrrninc i1'yrrrr faciiity was in coln;:rlinnce
rvith ilre Vr:r:nont REsislerrtial (larc Honre ltcgriations, 'l'he survcy slatemenl is encl:scd. Tlris
survey fburui thc nlost scriou5 tlcl'iuicney irr voul iacility lo l:e *'ielcstr'rreacl dc{ieicrtcies thal
oonslitute no actu;rl barrrr, irut wltlr pr-rtentinl lirr rnore tltan nrinirxrl hatln to lssidcnls.
Y*u must sul:rtrit a Flan oi'Corrcctic'lr. Ple asc iv:-ileltyire the Plan oi' {lcnecliort in the space
prnvirlcil or attach a separate docrrrncrrt. Ytur Plal of Correelio,r r'r1u$t irrilie*tc a cotnplelion or
(lorrection I)atc fi-ir.ra.i, d"tl.i.nc.y Subsurnlial compliarrce must be achicvcd by Novtttrbcr .1,
20181 tl:crcfore, ccrnplction d::tc:; nrtrst be plicr to rrrorr Novettrher J.2{-}18. Alieryot: ittlirrn: my
llllce that rhc ide::tificiliellcicncigs lravi: ltecr: addres.sril, a fililan'-rtp survcv rr'ill be condttcted
t() L'\raluiltc ctrntpli ancr'

ylur tille ot) thc bollor.tr ot'tlrc first ;;agc cf tirc rcporl, atltl reltt:'tt
this r*port to my ollit:e n(i later :l:arr Cctohrr 29. 2018.
Please sign, .late. aurl i;rilirale

l

lla_r:_o

Yrirrr

l {l' rrr':c l iq::*ili0C

I)0('

r

r'rrust coutuiu tltc firllou'rng.

Dioability and Aging Senrices
Liccnsing and Protectinn

Blind and Visually lrnparied
Vor:ational Rehabllitation

 L What nr:liorr

)'r:rr

will ltke lo corrcct the deflcieucyl

?. What measnres will b* prrt intt: placc (]l'rvhal syslrnr:c changes you rvi ll rtake tr) rltrstlre
that the deficir'nt practice does no1 recur:

3. Iloiv
4.

the csrrcglivc aclions

will

be nrcrnitored srr lhe delrcienl praclice does ttol recur; iltid

Thc clates by which ct:rrcctirre 6ction

will

be cotttpieletl.

l'he Departrxent is authorizeri to irnp,:se sanctions for f;rilure lo c{rrrecl a tlcficiency andltr failure
to provide prcof'of ccnecliorr by the specified Correcliult l)ate. l)cpending cn thc natur€ of the
virrlation.s, the folkrwing sanctit';rrs rnay be inrposed: adnrinistrative penallies ol'up to $ 10.00 per
rcsiclenl ur $100.00, u'hiuhsver is grc*ter', lor eacl'l day thc vioialion rcn'!*ins uncorrecled;
suspension, revocation rir rnodifieation of an existing liccnse: reJ'usal to renew n liccnse;
suspcttsiun ol'admissiun or tranBf'er ot-resid*nts to an trlternafivc placenent; iniunctive rclief to
cr:iojn any ael or omi.ssir^:n; arid thc appointmerrt of a re,.:eiver lor a tacility, lf you feel slrirt
conrpliance with the law or rcgulalior:s would irnpost a substantial hardship. y{)lr trray apply to
the Department for a variance, as stated uneler Section lll olthe Residential Care llome Licensing
Rcgulatierns. You nrusl elo so prinr to Ocloher 29' 2018,

linfqisseeu!&usJt
A

separate lelter

rvill bc ssnt rcgarding cnforccnenl aclion talten by the licen.sing agen*y

4l'uv-i.rl-1. -

Ynu :nay rr:qucst an iulbn:ral rsyil:rv o{'all or part o{'thc contenls of tlre notir;e al atly lirne prierr to
Octoher 29,2018, h1' calling Suaanrre L.eavitt. RN. MS, Assistant Divisian Dirccfor, or Cllayton Clark,

DivisionDirector,at{l{t!2)241-tt480. Allernativel},}ol: rnayappealthisdetcrrninatiottrrfvir.rlatitlnta
tlte Cornrnissioner of Disnbilirics. Aging and lrrrlepenelcnt I"iving wi(hin ltlle ert ( I 5) days of the date ol'
this notice by eatling {lt0?.i 241-{)ll5l and rcque:ting an appcal, You also l:ave tlre opliott rlf directl)'
appealing to the lJurnan Services Bnari irv reqrcsting a lirir hcari;rg with lhe l{urnan Scrviccs Board,
rvilhin thirrv (30) tJays of the date i:l'this noticc. Lry writing to tire lloard a1 l4-16 tsaldlvirt Streel,
l4ontpelier. Vl 05633"1302 ol by calling ihc l]oard at {$0?) 82S-253(r'

tl'you choose to pursuc eithr:"arr infnnna,l review or an appcal to tlte (lrrnlttissirncr attd you arc
dissatisficd tvitlr.the decision. you wor:ld als* hc enlitieci lo requesl a f'nirhearing, within thirty {3lJ)
days oI'the rlarr: of'th* informal revierv ol al:pt'al decisiolr. by cont*cting the l-lunrart Services lloard at
lhe acJclress ar phone nunrher listrd abc'r,e. \'lru hale ;r : iglrl to appear be forc lhc Board and ts Prescnt
rvitnesscs and olher evidence will'l rcgard to yrlur"case:. Y*Lr also hnve a righl la be re1:rcscnted by an
attorney al lhe llunran Services Boalcl lair lrearing.

 Please c:ot)tact ntc a1 {802) 241-A490 ii'you
S

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Enclosure

ec: Andrer"u While. l,ic*nsecl{,}wncr
Cotporalion Sclvice Corlpany, I{egistcred Agenl

(ltl€sll()lls.

 PR NTED. i0115/20't8
FORM APPROVEO
STAT'MLN t 0r Dfr;{:'gir0Es
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8_

0372
NAME OF PROVIOER OR SUPPIIER

WlNe

10/0312018

SIRE6IAODRE$S, CITY. ETATI, ZIP COOE
gO

ALLENWOOD AT PILL8BURY MANOR
{x{} rB
pRcfrx

ALLEN ROAD
SOUTH BURLII.IGTON, VT 05403

SUMIIiART SIAl EM€NT OF DCIICIENCTES
IEACH DEFICteNCy MUE1 re FRTCED€D SY
RCGt'LAlORY'R i-SC IOENTIFYING INTORN'ATICN}

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ROVIDEF'S gIAN OF CORRECTION

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R1tl0, lniiial Comments:

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{tir\clr fonEEcrtvE A{;.noN.!ll{itll l} *e
*ni)$3'REr€ReNCFn rC T'-.lF rlpPt{Opnffi

R100

An unannounced on $its survoy was completed
on 10/3118 by the Vermont Division of Licensing
and Protection The purpose of the survey was io
investigate a complalnl. The following regulatory
violatisns were ldentified.
R104;
SS=F

V. RESIDENT CARE AND HOME SERVICES

R1 04

5.1 Adrnission

5.2.a Prior ta or et th€ time of admission, each
resident, and lhe residenl's legal representative if
any, shallbe provided with a written admission
agreement which describes the daily, weekly, or
monthly rate to be charged, a desffiption of lhe
seruices that are covered in lhe rate, and all othet
applicable linancial issues, including an
explanalion of the home's golicy regarding
discharge or lransfer when a residenfs financial
status changes from privately paying to paying
with SSI oTACCS benefils. This admission
agreemeni shall specrfy at least how lhe follcnrving
serv,ces will be provided, and what additional
charges thete will be, if any: all personal care

services; nursing services; medisation
maragement; laundry; transportation; toiletfies;
and any additional services provided under ACCS
or a Medicaid Waiver program. lf applicable, the
agreement must specify the amounl and purpose
of any depcsit. This agreement must also specify
lhe residenl's transfer and discharge rights,
including provisions for refunds, and must include
a descriplion of the honre's personal needs
allowance policy

(1) ln addition to general residenl agreement
reguirements, ag.eements for all ACCS
shall include. the
TrrL€

LABGRA;ORY O;RECTOR-$ OR FRCVIDER'5i]FIP!iER RFP&[SLI{TATIVE'Ii .5IGNA]URI

STAIE FQF(M

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FORM APPROVED
STATEMENT OIJ OEFICIgNCIES
ANS PLAN OF {;ORRECYION

{xl)

PROVInERISUPPLIF lltcl.lA

{x?} MUtT!PLE

rnf NTlrlCAl ION NUMFER

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4372

STREET ADNRESS, CITY. STATE, ZIP CONE

NAME OF PRQ\IIDER OR SUPPLIER

ALLENWOOD AT PILLSBURY MANOR
1Vr'.\

ALLEN ROAD
SOUTH BURLINGTON, VT 05403
SO

SI,MMARY STATEMEN'I' OF OEFiCIENCIf S.
{EA{:H OHFiCIFNCY MUST BE PRECENED 8Y FULL
REGULAI'OR\' OA LSC IDII'{TIFYING INFORI'ATION}

tn

I:RFFIX

R104 Continued Frorn page

t0/03/2018

1

IIJ

FREFIX

TA(;

I'ROViOER'S FIAN OF CORRSCTII]N
{TACH CORRECTIVF ACT'ON SHOUID Ii€
CROSS-REF,:RFNCFI) lO THE APPRC)PlilATF
DEFICIENCvi

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I

R104

ACCS services, lhe specific rgom a*d board rate,
the amount of personal needs allowance and the
provider's agreement to accept room and board
and Medicaid as sole Payment.
This REQUIREMENT is nol met as evidenced
by:

Based on multiple reports from residents of the
the faciliiy, the iacility has faiied i{s fiduciary du$
to comply wlth lhe terms of the admission
; agreements to all current res;dents of the facility,
by failing to bill monthly for rent and
miscellaneous charges for each residenfs
apartment and agreed upon care ancl services.
This regulatory violation affects all residents
andlor their legally responsible financial parties.
i This is a repeat violation, as ihe facility was lound
to be out of cornpliance Wilh olher aspects of this
'i rcquiretnent on 8/15118. Flndings include:
Per interviaws 11l2l18 and 10l3l1B with facility
residents and staff, the lacility licensee has failed
to adhere lo the lerms of theirAdrnission
Agrsements for all current residents, The facility
has failed to send all residents a monthly bill of
the amount ovred for rent and miscellaneous
charges every month, as steted in the written
terms of the signed admission agreements, This
failure to comply wiih the agreement alsc violaies
each resident's right to review their financial
records upon request The faciiity licensee has
not explained in wdting to all residenls the
reasons for their failure to comply with the terrns
of each admission agreement and this issue is
causing significant distress to lesidents andlor
their legally responsible parties. Per interviews
with residents who wished lo be anonymous on
10l3l18,lhey were 'very upset' and concerned
months
have nst been billed for
that th
S?ATE FORM

VWGG11

lf coni{rilalion

shctl

? oj'?

 PfIINTED: 19115/201&
FORM APPROVEI)
STA1€MENT OF D€FIEIENCIFS
AND PIAN OT. CCHRECTION

(x1) PROVTDEn/suppt iER/cL:A
rDLN Iif  CATlON NL'MtsEq,

{x2} rrlllLllpLE CONSTRUC

A

I

{x3} IJATF SURVTY

IoN

cordPl.FTID

8U}LDINA:

U
IJ WING

0372

10r03r2018

NAME OF PROVIDER OR $LJFPLIER

STRFFT ADORESS. CITY. STATE, ZIP COOE

ALLENWOOD AT PILLSBURY MANOR

90 ALLEN ROAD
SOUTHBURLINCTON,

{x4)

SUMMARY STATEMTNT Of: OEF!CI'NCIES
{[ACX DETICIENCY MUST SE PRECEOED 8Y }'UI"L
REGULATORY OR I SC IDENTIF,YING INFORMATION}

rD

PR&FIX
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R104 Continued From page ')

ro

FREFIX
"lAa;

W

05403
PROVIDER'S PLAN OF CORSECTION
{EACH Ct]RRECl'IVE ACTION S'JOULP l]T
CRCST!.HT-FERENCEI] TO THE API'ROPRIAIE

{x5)

cotutPi"lll
IJ}\I L

oEFIcIENCY)

R104

since the March, 2018, No bills have been
received for April, 2018 to the present month,
September, ?018. There are no facility staff
employed at ihe facility to facilitate responses to
questions lhe residents may have regarding their
financial records and monthly billing history.
R145: V. RESIDENT CAREAND HOME SERVICES

R145

SS=D

5,9 c (2)
Oversee development of a writlen plan of care for
each resident that is based on abilities and needs
as identified in the resident assessmenl. A plan
of care fiust describe the care and services
necessary to assist the resident to maintain
independence and well-being;

This REQUIREMENT is not met as evidenced
by;

Fer staff interview and record review, the RN
{Registered Nurse) falled to develop a care plan
to each of the identified care needs for 1
applicable resident in the targeted sarnple,
(Resident#1) This is a repeat violation, as the
facility was found to be out of compliance with
this requirement on 8115/18.
Per record review, Resident #1 had been recently
diagnosed with a sardiac arrhythmia and had
physician srders for anticoagulant therapy The
residents care plan failed to address the newly
identified medical condition and the subsequent
intervenlions required to provide care and
monitoring for this condition. The failure to
address the identified needs in the care plan was
*ncJ

ETATE FORM

l,roleclion

VWGGll

ll

*nlinualion sheel

3

of

?

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FORM AFPROVED

sT TF[{rN?

OF

t}€rirctFltctf:s

AND FL.AN OT CCRRECTjON

l:( 1) FROVTD[p/SUFPL'IRtCL'A
rDENriFlCAr tON t{LMBEii

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STRT;T AOORESS. CIIY. STATE. ZIF COOE

ALLENWOOD AT PILLSBURY MANOR

90 ALLEN ROAD
SOUTH BURLINGTON. VT 05403

suMMARY STATTITEN

I

Or 0EFlClINCirt

MUST BE FRECEDGD BY TULL
REGUIATORY OR i.SC IO€N'IFYING INFORMATIOT{:

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R145 Continued Frorn page 3

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NAME OT PflOVIDgR OR SUPPL'ER

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FROViDER'S trIAN fiF CORRTC'ION
{':ACH eoRFECltVe ACT ON $lloul.t} BE
cli{rss.nF r EREhtcEE TO Ttlg Al'l{loPltlAl E

:x5]

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R145

confirmecj during interview with the DNS {Director
sf Nurses),

Rl

II]

V. RESIDENT CARF AND HOI,IE SERVICES

R178

i\)=t

5.11 Slaff Services
5.11,a There shallbg sufficient nurnber of
qualilied personnelavailable al all times tg
provide necessary care, to mainlain a safe and
healthy environment, and to assure prompt,
; appropriale action in cases of injury, lllness, fire
, or other emergencies,
This REOUIREMENT is noi met as evidence{i
I bv:

Based on staff interuiew and record review, the
facility failed to assure that ther€ were sufficient
staff on duty at all times to provide the necessary
care to maintain a sale and healthy enVironment
and to assure prompt appropriale action in cases
of injury, illness, fire or any other emergency
situalions thal may occur. This failure had the
potential lo cause harrn to any resident needrng
urgent eare and attention. This is e r€peat
violation, as the facility was found to be out af
compliance with lhie requi(ement on 8/15/18
Findings include.

Per steff interviews and staff schedule review for
the period from 819/18 - 10/3/18, the fecility failed
to have sufficient staff on dufy in the building to
assure the necessary care for Resident #1 , who
was dete!'mined to be nursing home level of care,
and required physical assistance of 2 -3 staff for
Activities if Daily Living (ADLs) including
assislance with toilelin g, translers, personal
hygiene and bathing Ouring interview wlth the
facilily Charge nurse on 1 0/3/18 at 4:07 PM, s/he
ion &t Llcensing
STATE FORM

\^/'GG-11

tlrrntinuBtron she€{ 4 of

7

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FORM AultrROV!:0
SINTEMENl Of DIF'CIENEIES
ANn PIAN 0!- CofqRECl tON

{x1} pnOvl{}€R/srJPpr.tFft rcLlA

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SIFFFT ADI]RESS, CITY. $TATE. ZIP CODE

NAME OT PROVIOER QF $T.JPFIIER

ALLENWOOD AT P'LLSBURY MANOR
{x{)

ALLEN ROAD
SOUTH BURLINGTON, VT 05403
SO

SUMMARY STAT€MENT OF I]EFICITNC}ES
II,ACH OSTICII] NCY MUST BE PREC€NET} AY FUI,I.
NE6U$TORY OR ,
IOEN'IIFYINS INfORMATION}

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PROVIOER'S
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DEFI(:IENCY}

l{ 178

confirmed that on 9t9l18, an evenrng shrft nurse
was the only slaff person on duty in the building
fot a 2 hour period {from I PM to 10 pM). A
writlen statement from the nurse who worked on
that date conlirmed the data and lime when they
were alone caring lor Zti residents, Tha charge
nurse on duly on 1CI13118 staled thal during the 2
hour period 9/9118 rvhen lhe evening nurse was
alone in lhe building, a resident w;th cognitive
impairment pulled lhe firc alarm and the fire
department responded. ll was delermined to be a
felse alarm however, if it had not been. or if there
had been some other type of emergency, lhe
resident requiring 2 -3 stafl for translers and atl
mobility needs could have suffered an adverse
outcome.
Per review ef ihe siaff schedules, there was only
1 staff person assigned to the 11 PM to 7 AM shift
on 9/7118 and 918118, and 't staff person was
alone on 9/15118 frorn 5:00 AM to 6:30 AM: lhete
were usually a rninirirurn 2 staff on 11-7 shift per
the Nurse Manager con{irmaticn on 1013118 at 2
PM. She conlir.*ed that 2 staff were needed to
assure timely care for Residenl f 1, who required
2 and al times 3 staff fsr transfers and all mcbiiity
needs.

ln addition. sn 9121118 through 9125 18 and agarn
on 9128i18 - 9/30/18, the 11-7 charge nurse was
required ls cover the shifl fsrAllenwsod and
Piltsbury Soilth, an adjacent and separalely
licensed facility. lf the charge nurse needed lo go
next door to Pillsbury South, that would also leave
only 1 staff person remaining on duty at
Allenirnod, presenting unsafe siaffing levels. per
the charge Nurse Manager.

alnd

STATE FORM

vwcc11

ll ccntrnnatinn shecl $ $l

t

 PRINl'E0r 10115/?01S
FORM APPROVF{]
STATIMENT f}F DEFICiENCIFS
AItP PI}N OF CORRECTION

(x1) P;1OV DEr{'SUPPi lf

RiCLTA

iDFN'i'IFICATIOil NUMBCR:

{x2}

A

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{x3) DArE $Ultv€Y

TIP[E cOt$StRUCTION

COfulPLTI ED

BU LO'NC

c
NAME OF PROVIDER OR SUPPLIER

ALLENWOOD AT PILLSBURY MANOR

S'REE AODRESS, CITY. S' AIE" :IP
90 ALLEN ROAD

TA€

R223 Continged FIom page

8

CODE

SOUTH BURLINGTON, VT 05403

SUMMANY STAl'€MEN I OF DEFICIENCIL$
lEACll OEFTC1ENCY MUST Be PRECFnFU 8Y FlJl.t.
RECUI.ATORY OR L$C IDLNTIFYING INFORMATION)

{x4} iD
PR':TI,X

I

0 wNc

0372

5

R223' VI. RESIDENT$' RIGHT$
SS=F:

ID

PREF}X

PROVIDFR'S PI}N OF CORRECTION
{EACt.r CORRECTIVE ACTION $HOtJlO BC
CI.{O$S.RFTERENCEO 1O Ti''E AITPROPRIAlE

{;{tl
aOryttri-! I a

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R223

R223

6.11 The re$ident has the right to review the
resident's medical or financial records upon
request.

This REQUIREMENT is not mei as eviCenced
by:

Based on intervjew and record review, ihe faciiity
failed to assure that each residenl has the right to
review their financial records upon request and
' that current tesidents had staff member available
for assisting wilh this righl. This practice has the
potential to affect all residents of ihe facility
Findings include:
Per inforntation received from residents of the
facility, the {acility licensee has failed to assure
access to the financial records of each resident.
As oi the complaint survey completed on 10/3118,
the facilily had continued to fail to fuliil the tetms
: of the resident adrnission agreements by failing tc
i bi{l fsr their month}y rent and services. During
interviews with residents who wished to be
anonymous on 10/2118, they were all distressed
at the lack of bills received: they all stated the last
monthly bill received was for the rnonth o{ March,
20'18. During interview, the only business office
employee available for the facility stated on
10/3118 at 2 PM that sihe did not have any
information regarding resident billing
practiceslprocesses. s/he slated lhat the
employee who used to oversee that area had
resigned the previous week and there was no
replacement stalf available to facilitate a review of
financial reoords if any residenl of the facility
wished to review these recordson

STATE FORM

ing and

VWGGI1

lf sodinualiol

sheel fi of

7

 PRINTEU: 10t1512818
FORM ATJPfIOVEI]
S

lAr FM;NT OF Di:f ictrNiri$
FtAI,i OF CORfi'C'!'INl{

,AND

tx!]

Paovl*eRlsttFPLlERicr.tA
tofN"r rFr{:A1,0N NUMBFn

{,cl frljl I rPLr co$$ lltt.tc'tlcN

A

NAIUE OT PFOVIDEN SR SUPPLICR

SlRFFT ADDR€SS.

ALL€NWOOD AT PILL$BURY MANOR

90 ALLEN ROAO
SOUTH BURLINGTON,

ix4)

SUMMARY 5TATLMENI OT' OEFICIENCITS
pY rl,lt.
{EACH OE-leE.rCY MUS' 8€ PtiECeOgO
R€CULATORY OR tSC r0€NTtFflN6 INFORMA;TO^ii

PREFIX

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$S-C;

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CITY- STAI€, ZIP EODE

ID

FR€FIX
TAG

vT

05403
PNOV}DER.S PLAN OF CI]RRFOIION
gg
lr;AcH coRR€cTrV[ ACTTON srtoulo
CR()$S'fiEFERENC*O T0 ;HE iFPnOFRtttI

iXii

r

*a)fiFLg:E

oFFlClgNCY!

VII NUTRITION AND FOOD SERVICES

R?38

.1.a. (7  The horne shall maintain eufficient food
sl,pplies at hand on the premises to meel the
requirements oi the planned weehly menus.
7

This REQUIREMENT is not met as evidenced
by:

Based on obgervation and staff interviews, lhe

facili$ failed to maintain sufticient food supplies
at hand on the premises to meet the
requirements of th€ planned weekly m€nus. The
lack of some menu ilems had the polential to
affecl all residenls ol the facility. l'indings include'
Per obeervations in the Pillsbury South kitchen on
1An118, several 1i2 gallon containers of milk
were in a plastic'bus' lnb: the FSD confirmed lhai
they were to be brought lo their adjacent facility.
Allenwood, because they had 'run out of milk thie
rnorning'. On 10/2/18 at 10:40, during interview
the FSD, who covers both Allenwood and
Pillsbury South. s/he stated that slhe had
received a few hundred dollars from the business
office's petty cash accounl to purchase bread,
juiee and aggs for bsth facilitiec (Allenwood and
Pillsbury South). The FSD stated that many
vendors were not delivering foods when ordered
due to a lack of timely paymenl and that he rnay
have to starl using lhe emergency food supplies
from the freezefs if things didn't get better soon

Fnd

STATE FOFIM

VWGG11

It

eodlinuatton sheei 7 o[

?

 Division of Licensing and Protection
HC 2 South, 280 State Drive
Waterbury V'f 05671 -2060
http://www.dlp.vennont. gov
Survey and Certification VoicelTTY (802) 241-0480
Survey and Certification F*r (802) 241-0343
Survey and Certification Reporting Line: {888) 700-5330
To Report Adult Abuse: (800) 564-16t2

Ociober 9, 2018 *Resending*

Sarah Holm, Manager

Homestead At Pillsbury

64 Harborview Drive
St Albans, VT A5478-4477
Dear Ms. Holm

The Division of Licensing and Protection completed a re-licensing survey and complaint
investigation at your facility on September 19, 2018. The purpose of the survey was to determine
if your facility was in compliance with Vermont Residential Care Homc Regulations. The survey
stotement is enclosed. This sqrvey found the most serious deficiency in your facility to be isolated
deficiencies that constitute no actual harm with potential for more than rnitrimal harm that is no1
immediate jeopardy. You must submit a plan of correction. Please writeitype the Plan of
Correction in the space provided or attach a separate document. A completion date fbr each plan
of correction must be indicated.
Please sign, date, and indicate your title on the bottom of the first page of the r€port and return
this report to this oftice no later than October 19' 2018.
Plan of Conrction (POC)

Your POC must contain the following:
a

What action you will take to correct the deficiency;

a

What measures will be put into place or what systemic changes you
that the deficient practice does not recur; and,

a

How the corTective actions will be monitored so the deficient practiee does not recur.

a

The dates conective action

will

will

make to ensure

be completed.

You created this PDF from an application that is not licensed to print to novaPDF printer (http://www.novgpdf.cor.ni

 you may also request an informat revierv of all or part of the contents of thE notice at any tirno
prior to.October 19, 20lS by calling Suzanne travit! RN, MS, Assistant Division Director, or
bluyton Clark, Division Dircctor ar (802) 241-0480. If you are not satisfied with the oulcome of
the informal revjew with the Division, you may request a rcvicw by the Commissioner of
Disabilities, Aging and lndependent l-iving. To request a review with the Commissianer. call
(802) 241-2441.
The Deparlment is authorized to impose sanclions for ftilure to colrect a deficiency and/or ftiiure
to provide proof of correction by the specified Correction Date. f)epending on the nature of the
violations, ihe foliowing sanctions may be imposed: administrative penalties of up to $10'00 per
resident or $100.00, whichcver is greater, for each day the violalion remains uncortected;
suspension, reirocation or modification of an existing license; refusal 1o rcnew a license;
suspension of admission or transfer of residents to an alternative placement; injunctive relief to
en;oin any act sr omission; and the appointrnent of a receivcr for a facility, If you leel strict
compliance with the law or regulations would impose a substantial hardship, you may apply to
the Deparlrnent for a variance as stated under Section III of the Residential Care }:Iome Licsnsing
Regulations. You must do so priorto Octobcr 19' 2018.
Appeals

As notcd above, you may seek an in{brmal rsview from Suzanne l,eavitt, RNn MS, Assistant Division
Direotor, or a Cornmissioner's review of this dosision. In addition, you have a right to request a lair
hearing with the Human Services Boarrl. Decisions by the Department of Disabilities, Aging and
lndependent Living can be appealed to the I'{uman Services l3oard pursuant to 3 V.S.A. $3091. The
request for a fair hearing before the Hurnan Services Boar:d must be made within thirty (30) days of.
your receipt of the notice of this decision, and can be made by writing to the Board at l4-16 Baldwin
Street, Montpelier, VT 05633-2536. You have a right to appear before the lloard and to present
witnesses and other o.idenoe with regard to the case. You also hsve a right to be represented by an
attorney at the lluman Services Board fair hearing.
Please contacl me at (802) 241-0480

if

1'ou have any questions.

Sinoerely,

Pamela M. Cota, RN

Licensing Chief

you created this PDF from an application that is not licensed to print to novaPDF printer (http:l/www.novapdf.com)

 PRINTED: W04,l2018
FORM APPROVEO

(xl)

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

PROVDeR/SUPPLIER/CLIA

(x2) MULTTPLE coNsrRUcTroN

IDENTIFICA?ION NUMBER:

A

54 HARBORVIEW ORIVE

HOMESTEADAT PILLsBURY

STALBANS,VT 05478

SUMMARY STATEMENT OF DEFICIENCIES

ID

gE PRECEDSD 8Y FULL
{EACH DEF}CIENCY MUST
REGULATORY OR

09n9120,18

STREETADORESS. CITY, STATE, ZIP CODE

NAME OF PROVIOER OR SUPFLIER

TAG

c

g.wlNG

0605

(x4) l0
PREFIX

{X3} OATE SURVEY
COMPLETED

SUILDING:

tSC

PREFIX
TAG

IDEN?IFYING INFORMATION)

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVEICTION SHOULD BE
CROSF.REFERENCED TO THE APPROPft1ATE

.

(x5)

C0l'tPtEtE
DATE

DEFICIENCn

R100

R100 lnitial Comments:

An unannounced onsiie re-licensing survEy, and
the investigation of one facility report and one
complaint, was completed by the Division of
Licensing and Protection from 9/18-19/20'18. The
following regulatory violations were identified:
R123

Rl23 V. RESIDENT CAREAND HOME SERVICES
SS=D

5.4 Refunds
5.4.a When a resideni is dischargad, the
resident shall receive a refund, within 15 days of
discharge, for any funds paid in advance for
each day care was not provided. ln the case of a
discharge to a hospital or other temporary
placement, the effective date for ihis provision
shall be the day the home is notified the reEident
will not be returning. For the puposes of
providing refunds, "day of discbarge" shall be
considered the day the resident's room is empty
of the resident's belongings, if those belongings
are too large or diffieult for the home to store
temporarily. The facility shall lemporarily store
small iteme such as clolhing and other personal
items if necessary.

This REQUIREMENT is not met as evidenced
by:
Based on staff interview and record review, the
facility failed to return the deposit of one resident
in the applicable sample (Resident #7) within the
required 15 day period after discharge, Findings
include:
Per racord review, Resident #7 and the legal
representative signed admission documents and
made a deposit in the amount of $4,950 on
LABORATORY

OR PROVIDER/SUPPLIER REPRESENTATIVE'S

1x6, DATE

TITLE

SI9NATURE

10/18118

SIAIT TUHM

€get

200111

ll conlinualidt

you created ihis PDF from an application that is not licensed to print to novaPDF printer (htlp:l/www.novapdf.com)

shal

'l of 5

 PRINTEO: fi1}412018
FORMAPPROVED
STATEMENT OF DEFICIENCIES
ANO PLAN OF CORRECTION

(x1) PRovroER/suPPLlER/CLtA
IDENTIFICATION NUMSER:

{X3} DATE SURVEY
COMPLETED

{x2} MULTTPtE CONSTRUCTION
A,

BUILDING:-

c
B. WNG

0505

09n9/2018

NAI\4E OF PROVIDER OR SUPPLIER

STREETADDRESS. CITY, SIATE. ZIP CODE

HOiIIESTEAD AT PILIrSBURY

54 HARBORVIEW ORIVE
STALBANS,VT 05478

{x4) rD
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES

t0

PROVIDER'S PLAX OF CORRECTIOT'I

tx5)

{EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR tSC IOENTIFYING INFORMATIONJ

PREFIX
TAG

{EACH CORRECTIVEACTIoN SHOULO BE
CROSS-REFERENCED TO THE APPRQPRIATE

COMPLEIE
DATE

DEFTCTENCY)

R123 Continued From page

R123

1

6/15/13, ResidEnt #7 passed away at the facility

onZl24l18 [which constitutes a diseharge].
During interview on 9119/18, the Executive
Director confirmed that to date the estate of
Resident,#7 hes not been refunded the deposit of
$4, 950.
R177

V, RESIDENT CAREAND HOME SERVICES

R177

SS=D
5.

t0 Medication Management

5.10,h

{5) Narcotice and other conlrolled

drugs must be

kepl in a locked cabinet. Narcotics must be
accounted for on a daily basis. Other controlled
drugs shall be accounted for on at leasl a weekly
basis.

This REQUIREMENT is not met as evidenced

by:

Based on staff interview and record review, lhe

facility failed to account daily for narcotic
rnedication for 'l of 7 residents sampled
(Resident #5). Findings include:

Per interview with the Executive Director on
9/19/18 at 1:15 PM, thefacility received a
pharmacy delivery of 10 fentanyl patches for
Resident #5 on 1119117. When the first staff
person to use these patches signed out one
patch on 111171',7 al7:57 PM, s/he entered the
number of remaining patches as 6. Having taken
,l0 in
the box, there would have
one patch from
been 9 remaining rather than 6. Subsequent staff
did not notice this discrepancy and continued to
rnd Prot6clion
STATE FORM

algt

200111

lf cofilinurlion

you created this PDF from an application that is not licensed to print to novaPDF printer (http:l/www.novapdf.csm)

shecl

2

sf

5

 PRINTED: 11/M12018
FORMAPPROVED
STATEMENT OF DEFICIENCIES
ANP PLAN OF CORRECTION

{x1)

PROVTDER.ISUPPLIEX/cLlA
IDENTIFICATION NUMBER;

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A.

BUILDING:-

c
09n9/20{8

3.

0605
NAME OF PROVIOER OR SUPPLIER

STREET ADDRESS. CIIV, STATE, ZIP CODE

HOMESTEADAT PILLSBURY

64 HARBORVIEW DRIVE
STALBANS,vT 06478

SUMMARY STATEMENT OF DEFICIENCIEs
(EACH DEFICIENCY MUST BE PRECEOEO BY FULL
REGUL/TORYOR LSC IDENTIFYINC INFORMATION)

(x4) r0
PREFX
TAC

ID

PREFIX

TA6

PROVIBER'S PLAN QF CORRECTION
{e.AcH coRREcTMEACTION SHOUID BE
CROSS.REFERENCED TO TIIE AFFROPRl TE

{x5l
COMPLTTE

DA'E

DEFTCTgNCy)

R177 Continued From page 2

R177

counl down from 6 patches, not notacing that 3
patches were missing, each time they signed out

a patch. The patch was ordered to be replaced'
every 72 hours, so slaf{ miscounted the narcotic
6 additional times, per the individual narcotic
recofd of Residenl tAS. The Executive Director
confirrned that when the discrepancy was noled,
further investigalion identified lhat during the
daily shift counts of narcotics, thE staff tlere not
actually visualizing and counting each patch in a
box, and did not notice the initial entry error of 6
rather than I on 11117117.
R190

V. RESIDENT CAREAND HOME SERVICES

R190

SS:D
5.12.b.(4)
The results of the criminal record and adult
abuse registry checks for all staff.

This REQUIREMENT is not met as evidenced
by:

Based on record review and staff interview, the

facility failed to maintain on file the results of 1 of
5 pr+employment background checks ol criminel
and adult abuse registry. Findings include:
During review of records provided by the facility,
no Vermont Crimlnal lnformation Center,
Vermont Adult Abuse Registry, or Vermont Child
Abuse Registry checks were evident for 1 of 5
employoes in the sample.
During interviewon 9118/18 at 2:30 PM, the
Executive Director confirmed that the facility did
not have these background check records on file
fort of 5 employees in the samPle,
DMsion
STATE FORM

and Proteclion
6ASS

200111

Itconlinuatlon 8he!t 3 ot5

you crsated this POF from an application ihat is not licensed to print to novaPDF printer ihttp://www'nqvapdf.co!0)

 PRINTED: 1119412018
FORMAPPROVED
STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(x1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER

{X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION

A

BUILDING:

c
A WNG

0605

ogt,t9t20t8

NAN'E OF PROVIDER OR SUPPLIER

STREET ADORESS, CITY, STATE, ZIP CODF

HOMESTEADAT PILLSBURY

64 HARBORI/IEWDRIVE
STALBANE,VT 05478

(x4)

rD

PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES

ID

{EACH DEF1CIENCY MUST BE PRECEDED SY FULL
REGULATORY OR LSC IDENTIFYING INFORMATDN)

PREFIX
TAG

R?06 Conlinued From Page 3

V. RESIDENT CAREAND HOME SERVICES

PROVIDER'S PLAN OF CORRECTION
gE
{EACH CORRECnVEAcIoN sHoulo
EROSS.REFERENCED TO THE APPROPRIATE

(x3)
COMPLEIE
OA'IE

DEFtctENcY)

R206
R206

SS=D

5.18

Reporting of Abuse, Neglect or

Exploitation

5.18.a The licensee and staff shall report any
case of suspected abuse, neglect or exploitation
to theAdult Protective Services {APS) as
required by 33 V.S.A. S6903. APS may be
contacled by cal li ng loll-free 1 -800-564-1 61 2.
Reports must bs made loAP$ within 48 hours of
learning of the suspected, reported or alleged
incident.
This REQUIREMENT is not rnet as evidenced
by:

Based on staff intsrviennr and record review, the
facility failed to report an allegation of abuse,
neglact or exploitation for 1 of 7 residents
sampled (Resident #5). Findings include:
Per intarview with the Eiecutive Director on
9119118 at 1:15 PM, the facility received a
pharmacy delivery of 10 fentanyl patches for
Resident #5 on 1119117. When the first slaff
person to use these patches signed out one
patch on 11117117 al7:57 PM. the entered the
number of patches remaining as 6. Having taken
one patch from 10 in tha box, there would have
been 9 remaining rather than 6. Subsequent staff
did not notice this discrepancy and coniinued to
count down from 6 patehes, not noticing that 3
patches were missing, each time they signed sut
a patch. The Executive Director confirmed during
interview on 9/19/18 that when the discrepancy
was noted, this allegation of potantial resident
abuse, neglect or exploitation was not reported to

the Division of Licensing and Protection, Adult
snd Prot€ction
STATE FORM

6899

28011'l

lf continuslion sheot 4 0t 5

you created this PDF fom an application that is not licensed to print to novaPDF printer {http://www'novaldf.com)

 PRINTED: 11l0{.n018
FORMAPPROVEO
STATEMENT OF DEFICIENCIES
AlrlD PIJN OF CORRECTION

{xl)

PRovrD€RlsuPPLlEWeLlA

0e)

IDENTIFICATION NUMBER:

A.

(xe) DAIE SUR\€Y

MULTTP E CONSTRUCTION

COMPLETED

BUILOING:-

c
NAME OF PROVIDER OR SUPPLIER

HOMESTEAT' AT PILLSBURY
(x1) rD
PREFIX

TA6

09/t9t20t8

B,

0005

STREET A9ORESS,

CrY,

STATE, ZIP CODE

64 HARBORVIEWDRIVE

STALBANS,VT 05478

SUMMARY STATEMENT OF OEFICIENCIES
{EACH DEFICIENCYMUST BE PRECEDED BYFULL
REGULATORYOR LgC IDENTIFYINO INFORMATDN}

PREFX

IAG

PROVIDER'8 PLA{ OF CORRECTION
(EA0H coRREcTrvEAcTroN sHoutD BE
CROSS.REFERENCED TO THE APPROPRIATE

tX5)
COUPLEIE

'pAl€

DEFICIENCY)

R208 C,ontinued From page 4

R206

Protective Sarvices, or the police.

STATE FORM

€l$

2001'n

lf cofilinutlion

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lhaal

5

of 5

 AcENcv on' FIuNtnN SeRvlcns
"rr..L"\mRMONTDnpaR-rnrpNT oF Dts.tetr'rrteso Acrxc
aNo INnEpENDENr LIVINC
Division of Licensinq and Protection
HG ? South, 280 State Drive
WaterburY, VT 05671*?060
httP:/www.dail.verm
$urvey and Certification VoicelTTY t802) 241-0480
Survey and Certification Fax (802) 241-0343
Survey and Certification Reporting Line: (888) 700-5330
To Report Adult Abuse: (800) 564-1612

"

October 22,2018
Ms. Sarah Holm, Manager
Homestead At PillsburY
64 Harborview Drive
St Albans, VT 05478-4477

Dear Ms. Holm:
Enclosed is a copy of your acceptable plans of correction for tlre survey conducted on
Septemher tg, iiitA. Please post this document in a prominent place in your facility.
lf
We may {ollowup to verify that substantial compliance has been achieved and maintained,
*u finOin"t your facility has failed to aclrieve or rnaintain substantial compliance, remedies
may be imposed.
Sincerely,

Pamela M. Cota, RN
Licensing Chief

Disability and Aging SerYices
Liccncing and Proteetion

Blind arrd Visually ImParied
Vocational Rehabilitation

 Q-{

!{ornr$rertd'P, I\
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t oF DEFrc,ENcrtiti

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II)[ NTIFICAT'ON I'IUMBEN.

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0911

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sTATF, ZIP f:OU€

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PREI'IX

'fAc

PROVID€F'S PLAN OF CLJ'tRECl'ON
{EACH CORRTC'IV[ ACTION SHQUI,O BT
(}ROSS"frEFTSENChIJ 1O I HE APPIIOFRIATE

lxi)

il?r{,Pi.f'Ii
la

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SEFTCtENCY,

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64 HARBORVIEW DRIV€

JMMA'IY STAltrMEN1 T}F OEFICI€NCI€S
{f:AcH tJEFrCrEtrcy MUSI 8E FRECSDEO BY rULl
REGULATORY $R I,SC ID€N'IiYIN6 INFCRMATIONi

PRI':IX

{xi} riAri; :iuRvltY

CONS IR\,rcliON

wrNG

STRet:r AD[)R€$S,

SI

{x,t} ro

F()RMAPPROVEI)

A lJrjlLti'N(i

0605
NAMT O': PROV1OER ON SUPPL'€R

PRlI{TEO; l0/09/2018

R100

Comments:

An unannourced onsite re-licensing survey, and
the invastigalion of cne facility report and one
complainl, was ccmpleterl by the Divisinn oi
l-ieensing and Frotecticn irom 9118-19/2018, The
following regulalory violations were idenlified:

ii1?3 V. RESIDENT CARE AND HOME SERVICES

R12:{

s9=O

5.4 llefunds
5.4.a Wlren a residant is rliseharged, lhe
residert shall receive a relund, wlthin 15 days of
discharge, for any firnds paid in advance fbr each
day cate was not provided. ln ihe case ol a
discharge lo a hospital or other temporary
placemenl, the cffective date for lhis provision
shali be the day iho home is nolified lhe resident
wlll nol be returnirrg. For lhe purposes ol
providing reJunds, "day ol discharge" shall be
considercd the day the resident's roorn is enrply
of the residenl's belorigings, rl those belonging$
ara loo large or difficult for tlre home to slore
tomporarily. lhe faciiily shall temporarily slore
snrall items such as clolhing and olher personal
items if necessa/y

l

lhis RFQIJIREMSNT is not nlet as evidenced
by:

Based 0n slaff inlefvlew and record review, lhe
facilily {3i1s6 lo return the deposit of one resident
in lle applicab,e $arnple {Resiclen{ #7) within tlre
required 1li rlay perod after discharge. Findlngs
include,

Per recorrl review, Resident #7 and the legal
reprelenlative sigrred admission documenls ancJ
mad€ a rleposil :n lhe amounl of $4,950 on
6115113 Residenl #7 passed away at the iacility
LAITORAIQT:IY DlngC

STATT TORM

i()n ii {Jli PtlCVjt] EntSUPFt.'l:R rigPRFSEN

frlT

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 PFINr€t):10/Ogl201B
rORM APPROVED
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lA

:OfNTIFICAIIOH NUMAER

ANO PL,\N OF CORFECI lON

g wrN(:

0605

_

...*

NAME OF. PROVIOFR OR SUPPLIEN

3TRIEI AODRSSS- Ci1Y, $TATE UIPCODF

HOMESTgAO AT PILLsBURY

64 HAREORVIEW DR]VE
ST ALBANS, VT 05478

S'A1F-MEN T OF NIIFIEIENCIES

lx{} rn
lAc;

R123 Conlinued From page

1

R'S p{AN

.Q

FRI

(eAcH
oEFrc'lNcY MusT 8€ FReC€DED BY Furr
'UMMARY
REGUtAlOftY ON LS(: IDENTI''YINC INFORMATIONI

FITEFIX

ix3) 0AaE iurivgY
corirPt f T€s

lx2) MUr_T!!tC CONSTRUCflON
A BI'II.DING

TATl

IX

Uf {:()ttRECTr(}N

{fAcil conRtcTtvE Ac troN 5ucrl' ro

IROSS.R[.lrRrNCEO 10

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A?PfiOPft]^l

I

cot$'.€ tl:
DATf

R123

an 2124 I I I [rvlr ich canst itutes a eJ isch orge],
Durirrg irterview on

9/19i18, the Execuiive

Director celnfirmed thal to dale the estale af
Resident #7 has not been refunded the deposit ol
$4, 950.

Rl77 V.ITESIDENT CARTAND HOiXE SERVICES

R

177

SS-D

5.'l {i Mecjication

Managemert

5.10.h

(S) Natcotics and other controlled drugs must be
kepl in a losked cabinel. Narcolics musl bs
accounted for on a daily basis, Other controlled
drugs shall be accounted far on al least a weekly
basis.

lhis REQUII1FMENT is nol mel as evldenced
by:

Based on stat{ inlerview and reccrd review, lhe
facility failed lo accounl daily for narcotic
rnedicaiion for 1 ol 7 resider.rts sarnpled iResidenl
/15). Findings include:
Per inlerview wilh the Exeeutive Directsr lrn
9/1S118 at t'15 PM, lhe lacilrty recetvpcj a
pharlracy delivery of 10 fentanyl pstcnes for
Resident /I5 on 11/9/17 When the first slafl
person lo use {hese palches signed ou1 one
palch on 11117117 all'57 PM, slha enlered lhe
nunrber ol rerrraining patches as 6, Having tckell
one pBtch from 10 rn tlre box, there would havc
been I remainirrg rather than 6. $r.rbaequenl staii
d,il nol nolice lhis drscreparrcy and continued lo
count down frorn 6 palches, not noticing ihat 3
orltl

S'TNTI FORM

?:r)01 t 1

lto(rlt lru:rlrorl 5:iuer

I rtd

 PRINTED: 10/09/2018
FORMAFPROVED

of
SIATIMGNI Ot f, l:f ICILHCIES
ANO Pt AN

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ix

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0605
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$I

RT"EI AIJORESS. CITY. STATE.

64 TIARBORVIEW DRIVE

HOMESTEAD AT PIT,LSBURY

ST /\LBANS,

SumnARY STAI€tltEHI OF OEf lC,[.NCIES
(r^c[ oEfrcrrNcY MUst 8E FnecEDED BY FUtt
RE{JUIATORY OR tSC IDEftTIFYING  t{f ORIIATION}

R17?

Continued Frorn page

IIF

912018

COI)F

VT 05478
Fnovrorfil: PIAN or connec'ftOir
tfAclr c{}Far-cllvr AclrcN g,{oulo gg

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APPNOPRIATE

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{1177

palches were missing, sach lirne lhey signed out
a pslch, The patch was ordered to be replaced
every 72 hours, so stetf miscountecJ lhe narcolic E '
addilional times, ger the individual narcolic record
of Resrdent fls Th6 Execulrve Director conlirmed
that when lhe discrepaney was noted, further
investigaticn identified that during the daily shtll
counte of narcolics, the staff were not actu€lly
visuelizing and c,:rnting each patch ln a box, and I
did not nothe lhe inilial entry error of 0 rathet than

I qn 1ll17rl7

R190 V- RESIDENT CARFAND IJOME $ERVICFS
SS"D
5.1?. b.{4

RlSO

)

The resull,s sl the crirninal recofd arld adull abuse
,egislry checks for all staff.
This REOUIREMENT is not met as.svidenced
by:

Based on record rguiew and slafl lnlervlew, lhe
lacllity failed to rnaintain on lile the results of 1 of
5 pre-ernptOymenl backgrOund checks ol crimtnal
and adull abuse registry" Findings include'

During review oi recorrls provided by the facility,
no Vermonl Criminal tnlormalior Csnier, Vermont
Adull Abuse Rsqistry, or Vermont Child Abuse
ttegislry rnecks were ovident for 'i of 5
ernployeer irr the sample.
Durrng intervirrwon 9118118 al ? 30 PM, the
€,xeculrve Oireclor cnntirmed lhst lhe lacilily did
ilol have lhese trasKground check records on trle
lor 1 ol 5 ernpioyees in the sample.

STATT IORM

!ti1

?ooiil

il

!:o4k[ilal i!n.sl{t!

3 nl

,1

 pRINTED. r0/09/2018
FORM APPROVFN
$TAl'EluleNT OF OEFICI€NCIES

AN8 PLAN OT CO'IRE{:TION

(x

I

)

PROVTOERT$UPPu€ri/CLiA
IOf N''FICATION NUMOER,

tx2J MULI

a wtNc

0605
NAMF OT FIIOVIi}EN OR SUFPIIER

HOMESTEAD AT PILLSBURY

?A6

CON$ rtrUCTION

{xx) 0J\1e suRvEY
gOMPt€TEO

c

_

SIREETAOOEe$S, ct ry, 5lATt, etF CODE
6,1

HARBORVIEW OfiIVE
VT 05478

ST ALBANS,

SUJUMARY SlAIE[4 E8T OT OEFICIENGi[$
{€Acfr D€F CrENcy tilJ.5T ftF IREGECTED BY FUtL
tItGUIATORY OR L$C lDENTlFYltlG INFOnMAT ON)

{X4} rD
PSEF!X

rPrI

A. 8UlrDtN6.

PROVIDER'S PIA}I O': {;ORRECTION

ID

{F-AC}I Cf)RREC'ilVE AC lloN SHOULO 8E
CROS$.RFF ERSI.ICE O TO TIiE APPROPf{N]C

PREFIX
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R20B Conlinued Frofi page 3

R206

R2O6 V. RESIDENT CAREAND HOME SERVICES

R206

ES*D

5.18

Reporting of Abuse, N€glect or
Exploilation
5,18 a The licensee and staff shall report any
case of suspecled abuse, neglect oi exploitatlon
ta lhe Aduli Proiective $ervices {APS) as requiredi
by 33 V S.A. $6903. APS may be contacted by
calling loli-free 1-800-564-1612. Reports musl be .
rpade ta APS within 48 hours ol learning of the '.
suspected, repofted or alleged incident.
This RFQUIRENIENT is not mbt as evidenced
by:

Based on staff interview and r€cord review, Lhe
lacility failed to report an allegation of abuse,
neglect orexploitation far 1 6t 7 residents
sampled (Resident f5). Findings lnclude:

r

Per inlerview with the Execulive Director on
9/'19i18 et '':15 PM, the facillty re.ceiverl a
pharmacy delivery of 10 f€ntanyl palches lor
Resident #5 on 1119/17, When the first staff
per$on to use lhese patches siglred out one
patch on 11117117 at /:57 PM, slhe entered the
number of patches rernaining as 6. Having {aken
one palch fiom 10 in the box. there would have
been I remaining ralher than 6 Subsequenl siafl
did not notice this rliscrepancy and coniinued to
count down kom 6 patches, not naticing thal 3
paiches were rniesing, each tirrre lhey signed ou{
a palch The Executive Director gonfirmed during
inlerview on 9/19/18 thal when the discrepancy
was noled, this alleoation of polential residenl
abuse, neglecl or exploitaiion was not reporled to
lhe Oivisir:n cf Licensing and Prolection, Adull
Protective Services, or the police
nn,tsln0
STATE FORM

?o0111

i'Corrtinr,slrOn alrc(:l ,l ot 4

 LA/L8'lL8
Homestead Pillsbury Plan of Correction-

R123-Resident refund for Resident#7 has been paid October

L7,2AI8. (see attached proof of payment)
Resident refunds will be returned to any resident
Discharged by the

1,5th

day after discharge.

ED

will oversee all resident refunds are returned within

1-5

days of discharge. This has been completed 10/18/18,

R177-Nursing staff have been reeducated about narcotic

counting policy and procedure.
Counting of narcotics will be supervised by a charge
Nurse or med tech at the change of each shift or charge
Nurse or med tech on the cart. To ensure all narcotics

are accounted for.
DON or RN oversight will do random (weekly)

observation of narcotic counting to ensure policy and
procedure are being followed.
This corrective action has been completed L0/18/18.

 R190-New employee checklist has been created to ensure all

background checks are completed prior to starting work.
ED

will oversee each new employee's background checks

are completed prior to beginning work. ED will ensure
all background checks are kept in on site.
This will be completed by rcn8./LS.

R206-Any suspected abuse, neglect or exploitation will be

reported to APS within 48 hrs.
Reeducation will be provided to all staff about

reporting abuse, neglect or exploitation by 10131/18.
This will be overseen by the ED if any incident occurs.

 10tt1t2018

Peymonl 16gr11t -

dr*ro,coril

cHAsE€)
Frlntrd from Chrs€ Perton.l Ohllnn

iend on

)st

1?, 201

I

Dellver by

Statug

24

tunded

Oct

201 8

Peyc€

Amoun
$4,545.5t
Resident Refund

Status

Funds for thls palrment have been

withdrawn frorn your available balance,
whlch has been updated to reflect the
payment.
Faid

frorn

CHASE CHECKING {...

Memo
Transaction numb'er

1i1

 /.'q_\mRMONT

Acrcxcv or' [IutuEn Snnvlcns

f)r p^"r

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ili il TrT.i..*!,[il"

H{i 2 South,280 Statc Drive
Waicrbury VT' 055? l-2060
t{lpt'lvvsw. dn vquqry,ep-Y

Survey ancl Certificalion VoicelTl'Y (802) 241 -0480
To Report Adult Abuse: (800) 564-1612
Survcy and Certification Fax {9AU 241-A343
Survey and Certificalio:r Reportirrg Line:i888) 700-5:i30

October 12, 2018
Rssemade Provetto, Manager
Pillsbury Manor - South

20 Harbor View ft.oad
South llurlinglon,

VT

05403-7850

Dear Ms. Provctto:

'lhe Division of Licensing and Protection cornpleted a complaint irrvestigatiorr a{ yaur fbcility on
f)ctober 31 2018. The purpose of the survey rvas to dclermine if your facility was in compliance
with the Vennont Residential Care Home Regulptions. The survey statclneni is encloscd. l'his
survey lound the most serious deJlciencies in your facilily to Lre isolated deficiencies that
cor:sti{ute aeiual harrn, al(l:ough not imnrcdiate jeopardy.

You nrust subnril a Plan of Correc:tion. Itlcase write/type the Plan of Correction in the spacc
providcd or allach a separate docun:ent. Your Plan of Correclion must indicate n complt:lion or
Correctiott Datc for each r"lefici{rncy. Substanlial compliance must be achieved by Novernber 3,
201S; therefore, completion datcs tnust bs prior to or on Novenrber 3. 201 8. Aftcr you infbrm rny
ollce thal tlre identified del'iciencics have been addrcssed, a lollow-up survey will be conducted
to evaluate conrpliance
Please sign, date, and indicale your litle on the bollorn of the lirst page of the rcporl, antl retur:r
this report to nry afficc no later thar, Oelobcr26120l&.

!:!uu-!lll]!:'i!uu-01]!'l
Your PCiC rnust cor:tain the followirrg:

L What aclion yol rvill

take to eolrect thc deficicncy;

2. Wlrat rxcasures will be put into placc or what systemic changes ynu will makc to ensure
lhat the deiicierrt praciice does not lccur;

L

l low thc corrcclive actions

4. l'he dates

will

be monitorcd so the deficicnt plactice does nol rccur: and

try which corrective aciior"l

Disability and Aging Scrvicer
Licencirtg and Protection

will

be colnpleteri.

Blind und Virually Imparled
Vocntional Rehabilitation

 1'he llepaltrrrent is authofized to im;nse sanctions fcrr failure to cot'rect a dcficiency an#or failure

to provide proof of correcrion i:y the specifiecl Correction Date. Depending on the nalure of lhe
vioiarions, ihe following sanctions may be imposed: admirristrative penalties of up to $ 1 0.00 per
residenl or $100.00, whichever is grcater.'fnr each day the viclation remains unconected;
suspension, rcvocation or modification of an existing license; relusal to renew a liceltse;
suspepsion of admjssior or transfer of residenls 10 an altemaiive placement; injunctive relief to
enioln any act or omissionl anrl thc appoir:tment of a receiver lbr a fac.ility: lf you feel strict
compliance with the law or regulations would irnpose a substantial hardship, you may apply tc
the Department lbr a variance, as stated under Seclion'l1l of the Residential Care l{ome Licen.sing
Regulations. You must do so prior to Octobcr 26,2018,
Enforcernent

A

{e!ia!

separate letter

will

be .sent regarding errfcrcement action taken by the licensi:rg ags:lcy

Appcals

You may reqnest an informal review of all or part of the contents of the notice at any tirne prior to
October 26,2018rby calling Suzanne Leavitt, RN, MS, Assistant Division l)ireclor, or Clayton Clark,
Divisiog f)irector, at (802) 24 1 -0480. Altematively, you rnay appe al this determiration of violation to
the Commissioner of Disabilities, Agir:g and lndepenrlent L,ivirrg withirr fifteen ( I 5) days of the date of
this notice by calling (802) 241 -0353 and requesting an appeal. Yon also have the option of directly
appealing to the l,lunian Scrvices Board by requesting a fair hearing with &e I luman Services Board'
-irtri" thirty (30) days of the <late of this notice, by writing to the Board at 14-16 Baldwin Street,
Montpelier, VT 05633-4302 or'oy calling the Board at (802) 828-2536.
you choo.se to pursue either an infusrral review or all appeal to the Cotrrmissioncr and you are
eiissatisfied wilh the decision, you would atso be entitled to request a fair hearing, within thirty (30)
days of the date of thc infbrmal review or appeal decision, by cotrtacting the Human Services Board at
the address or phone nunrber listcd above. You have a right to appear bcforc the Board and to presenl
wilnesses ancl ol.her crvidence rvith regard to your case. Yrtu also have a right lo be represented by an
attoney at the l{uman Services Board fair hearing.

lf

Please coillact me at (802) 241-A48A if you havc any questions-

Sincerely,

{)a,*h.wLa:**tz il
Pamela M. Cota, RN

Licensing Chief

cc; Andrew While, Licensee/Owner
Ccrporation Service Company, Registered Agent

 8f-;* :TERMONT
Dgpanrnlnr\ir

Acexcv or Humnn Srnvlces
aNn fNus,pr:riDENT Lrvrxc
vi slrrr: I I !.,i $e lsllg3 rl d-]' hll s*Lon
llU 2 South. 2ll0 Stalc Driye

or Dts.nntLlrrts, AclNc
D

r

Wltrrbury V1'

.

0567 I -2060

b11p.1.1,!11vt1..qt-0il,vsrttl!'!-ggY

Survey and Uenificatio:t Voicell'T'Y
Survey and (lertificatian Fax
i<iurvey and Ccr"ti{lcaliott ltrporting l,ink:
'I'o Rrplrl :\ilult Abuse:

il{0?} ?41-0480
{802} ?41-0343
(8118) 700-5330

1800) 561'16tz

VIN T]I,R'I]I*IEN MAII,. ITRR
Nove ruber 6, 201

I

Ms. Ilarbara Moynar:,
Allerrwood At Pillsbury Mnnor
?{} Allcn Road
Sorrth llurlington, VT {}J4{}3-7856
!lg;

N nt isg--q!'

[]t'rrt:.t$iri Iu

I

ttt

1

Irsc

.$itt,tc ! ir

l tr

Dsar Ms. Moynnn
On Octoi:el I 5, 201 8. the llivision of Liccrrsing and Protecliorr {llLP) senl you the rcsu}ts of the
Octoher 3,201n, iiurvey at your facitity. lrr lhc tictober 15, 20lll, lcttrir, DLP required a l)lan of
Correcticn (P0(:) firr all ci{ed deficiencies. I)L,P al.so set a eompliancc da{e trf Novtmbcr 3, 2018n tbr
ail cited dcficicncies, including the defisiency regarcling Residential Clarc llontc rcquircntrttt 5.2.4,
specil'ically. the failurc lo bill rcsidents for thsir t'oilm, hoard ar:el persrxral carc.
As af

Allenwood at Pillstrurl'Ma::or has failcd 10 cor'Iccl, at a rninirrulrr, lhe deficicncy at 5.2.a
bl,Novcnber 3,2{i18. Per interview with l'aeility stal}'ciuling thc mornirg of Navcnrber 5.2018, hy a
Registered Nnrse survcy{,r who is r"lrrsite at thc Sout}r Burlingtern cilnrpus. residenls lrave :tot yel
rcceivcd bills lbr llreir roonr, boarrl and personal *rc since thr ejeficicncy was issucd. Iitirlhcr,
Allenwood at lrillsbury has failed'to subrnit an5, P[)C for the dcficiencies regarcling billirrg lesidertts.
rcsi,lcut refurrcls, and rcsidenl rights to rcviov finanei*l rccortls.
toria1,"

!-aretic';.rs

Based upon thc lhjlurc to con'ect at least orrc violation by lhe dale indicated anel llte failulc to submit a
comprehcnsir:c Flan olf]orlection l'or eash de{lcienrr), iderr{illctl durilg thc October:. 2f}18,
itrvestig,ntion, ihc Divisirrn is prepared to irnpcse szirctions in acccrdalcr-, rvitlt 33 V.S.A. S7111.

Di*ability and Aging Sen'ices
tlcensirrg snd Protection

Blind and Vicually Imparied
Voeational Rehabilitatlon

 ln the rrr'riice, daled Octnber 1 5, 201 8, that accon::pnnied the Oclotrr 3, 2018, violations" irrcluding the
violation regarding biilirrg, the l)ivrsion notilled thc facility that cnforcenrent tcntcrlies nray irrclude
suspencliug adnrissi{3us to )'otlr faciliiy in lhe event tlrc viglaiitrns rernained unc,lrrected. Further,l3
V.S.A. $?l I l(llx3) pror,ides thal if the liccnsirrg agency rsquires corcctivc aeiii:'n arld lhc lacility lras
nol couecied thc violation by the tlnre specitied, as is the case here, the liccnsing agelrcy nray take such
furthcr aclion as it deems appropriate under lhis section. Finally, Section 4. 1 5.c of the ,tesk/c ntid ( ura
Hume l.ir:en,ring lleguluti<sns aullml'izes thc irr:position o;5snclions for fbilure to telum a plan ol'
corrcclive aciion.

Baqlrt Aq$t$"qrr;
Basetl on the abuve, the Divisicn ol'i"icmsing and Profectinn is imposing a Ban on Admissions,
effectivc upon rcceipt of this notice. J'his notice ha* bcen sent via certified rnail, feluff r-*ceipt
requestcd, to conllrm the daie ol rece ipt. No fieN, re.rid'ents nny be ndnitted nfur that dnte.

'l'he Ban on Ailmissions u,ill continue until the honre achieves conpliance wirh all Rcsiriential Care
I lon:e regulatiurrs and snbnrits a conrprelrcnsivc POC,' in response ts ihe tlctober 15. 2018, lrtter'. A
notification will he senl at ttre tin:c the bnn is lilied; and tlre horne may not admil any nsw rssidents
until notifierl by ihis Divisinn that the ban has been li{ie.l. This does nol npply lo rc-admissions of
residents who rurr*rrlly residc at lhe homc at the time of reccipt of this lellcr, who rer;uired a
tempeirary transfer to nnother clre sctting or therapeutic lcave.
A.ppeal

You have the light to appcal this dccision. Yot nray rcquesl a review of this decision by corltacling the
Comnrissisner ol'Disabilities, Aging, and Indcpendent Living within fiftcen { I .5i days of the dale rrf

thisnotice.'Iorcquestarrappealwiththefornnrissioner,call(S02)241-(l353,Youmaynls*r*qries{a
firir henring with the l{uman Services L}oard, rvilhin thirty (30) tlays a{icr thc datc cf'the
(lon:ruissioner'"s dccision. or within rhirty {30} days alter the dnte of this nctice. by writing tt lhe Boixd
at l4-16 Baldrvin Street. Mr:rntpclier. V'l'f)5633-4302 or by calling the Board sl i802) 828-2536.

Sincerely,
t

J

,-r

*:," L -i

Parr:eli.r

M. Cola, l{N

Lice:rsirrg Chicl'

cc: Sluarl Schrrrr. Cerrcral ('cur:sel
Scan Londerg;lrr, Slole Long lerrn

Carc Ombudstt:an

Arrdrew White, Liceusce
Corpolntion Service Iionrpany, Rcgistelccl Agerrl

 ,#ff"€* "VERMONT

Acnxcv or flutwnx Srnvrcns
DnnanrnacNT <rF Drs,q,grr.rrrts, Acrxc exo InoBpBNDnNT trvrxc
Oinisin::r-"e l'-Licensi[s,4rtd PllJtls !:st3

l-lC ? South. 280 State Drive
Waterhury VT 05671-?060

Utplua.n:deiksllqrlsoY

Survey and Certification VoicellTY
Survey and Certificalion Fax
Survey and Certification lleprrt'ting t.ink:
To Rcport Arlttlt Abuse:

(80?)
(802)
(88ff)
(800)

241-0484
241-0343

700'5330
564-1612

VIA CF,RI]FIED MAII.,. RRR
Novernber 6. 20i

I

Ms. Birrbara Moyrran,

Allenwood At ltillsbury Manor
90 Allen Road
South tlurlingron,

VT

05403-7856
li"c ; .N

lrt"gg-alfrrrrsgl

"tr1-lj;111l$s._:i4rl!1jr,'l$

Dear Ms. Moynan:

On Oclnber I 5, 20   S, the Divisicn of Liccnsing and Proleclion {DLP} sent you the rcsults of the
Octoher 3,2018n survey qt yow facility. ln the October 15,2018,lefter, DI-P required a Pian of
Coruection (POC) for all cited deficiencies. DLP alse set a compliance dale of Novnmber 3, !018, fhr
all cited deficiencies, including the deficieucy regarding Residcntial Care Llnnre requiretncnt 5.?.a,
specifieally, the failure ta bill residents ftlr lheir room, board and personal care,
As of toelay, Allenwood at llillsbury Mnnor has failed to con'ect, at a nininutl, the deficiency at 5,2.a
Per inlsrview with facility staff riuring the rnorning of Noventber 5, 2018. by a
by November l, 201
Regislcred Nurse survcyor who is onsite at the Soutlr Burlington canlpus, residents have not yel
received bills fi:r lheir room, board and personal care since thc deficiency was issued. Further,
Allenwood ar Pillsbury has fbiled'to subnril any POC ibl the rieficiencies regarding biliiry residents,
rcsident refurttls, and re sidelrt riglrts to revicw finarrcial records.

L

$srslia.us
Based upon the failurc to cortrcl at least one violation lry the date indicated nnel the failure to subnrit a
ceimprehensive Plan of Correclion for each deficiency identified dtu'ing {he Oclober 3. 2018.
investigation, {he Division i}^ preparecl to inpose sarcticlns irr accordance with 33 V.S.A. $?l11.

Dicabtlity and Agiry Services
Llccneing and Protectlon

Blind and Vtcually Impnricd
Vocadonal Rehabilitation

 In the notice, daterl October I 5, 201 8, that accompanied the October 3, ?018, violatio:is, including the
rrinlation regalding Lrilling, the Division notified thc faeility tlrat errtlbrcen:cnt ren:eclies nray include
suspending admissions t$ yorir faciiity in tlie event tlre viclatians remained uneorscted. Irurlhet', 33
V,$.A. $7111(bX3) provides thur if the licerrsing agcncy requires corectivc action and llre facility iras
nol conect€d the virrlaticn by the tirne specified, as is the case here, lhe licensing agency nray take such
further actia:r as it deems appropriate under this seclion. l"inally, Seotitln 4.l5.c ci'the r{esiclentiol ('ttre
Home l.it:g11.sing llegulatictrts sutlrorizes the imposition of sancticn$ for failure to retu:'n a plan ol'

corrcclive action.

Een-al3d$isslqr"s
!]ased on thd abtiveo the Division of [,icensing and Prsteclion is imposing a Bnn rn Admissions,
eff*clive upon receipt of this nofice. 'fhis nr:tice has been sent via certified mail, return receipt
requested, to confirn: the date cl'reecip?. No new residentc mny be adnittecl alter lhnl dab.

Tl:e Ban on Atlmissions will continue until the home achievcs cornpliance with all Rcsiderttial Care
Hnme rcgulatioris and submits a colrprclrensive P{}ll in rcsponse to lhe Octaber I5, ?0! 8, letlcr. A
:rotification will be sent Bt lJrc tinro the ban is ljfled, and the hcme rnay not *dmit afly new t'esidents
tuntil notified by this Division that the ban has been lifted, This does not apply to re-sdmissions of
residents $'ho currerrtly rcside st the honnp at lhe time of reccipl of this lettcr, who rcquired a
temporary lransfcr lo another eare settitrg or therapeutic leavc.
Apoeal

You have the Light to appeal this decision, You rray reque$l a review of this decision by conlacling the
Conrmissiolrer rif'Disabilitie s, Aging, and Independent Livirtg within fifteen ( l5) dnys of the date of
this notice. lo requcst an appeal with rhe fummissioner, call i8ft2) 241-03.53. Ynu may also reguesl a
fair hearing rvith the l{runar: Services Soard, within thirty (30) days after tlrc date of the
L'omniissioner's dccision, or wilhin thirtl, {30i days aftcr thc date of this notice. by writing to tlie lloard
al l4-16 Baldrvin Street, Mr,rntpelier. V"f 05633-4302 or by calling the Board at {802) 828-2536

Sinccr*ly,

,t

,' ./

!'tlti*-'"
Panre la

t

M. flota, RN

Licelrsing Chiel'

Schurr, (ieneral Cerunsel
Sean Londergan, Slate Lnng Terur Carc Ombudsrnan

cc: Stuart

Audrerv White, l"icensee
(,lorpora lion

S

erv ice l--or n pany,

Ilcgistclcd

A gcrtl

 d*€- "\{ERMONT
DspAnrIuENT oF

Acnxcv or Huu*n Snnvrcnn
l)rsrsrrrrrrs, Acrxc .lxn IxnrpsNDENT Lrvrnc
U-r,isjgr

fli,qg.astj]ff'rld.ll$l-ecllan
l-lC ? South,280 State Drive
!

I

Vl. 0567 -2060
lf gp;!\lYrYdAl-l.tstlrt n t €g1f
Survey and Certificatian VoicellTY (802) 241-0480
Waierbury

1

Survey and Certilicatior: Fax (80?) 241-0343
Survey and Ccrtificatiort llrprlting Link: (888) 700-5330
To Rr'purt Ailult Abuse; (800) 564-1612

VIA (IERI'II.IED MAII,,

RRR

Novernber 6, 2018

Ms. Barbara Moynan,
Allenr",ood At Pillsbury Manor
90 Allen Road
South llurlington, VT t)5403-7856
li_s:l!i:UeSr).f Propouill, rn lr:rnrt,rcj-fut:t:t irUI
Dear Ms. Moynan:

()n C)ctober 15, 2018, the Divisian of Liccnsing tnd Prcteetion {DLP) sent you the rcsults of the
October3,20lS,sulvcyatyourfacility. lnthcOctoberl5,20lS,lettcr,DLPrequiredaPlanof
Correction {POC) for all cited deficiencies. DLP also scl a conrpliance dale sf November 3, 2018, lbr
all cited deficiencies. including thc deficiency regarding Residenlial Care J-lonre requiremcnt 5,2,a,
specifieally, the failure lo bill resider:ts for tlreir room, board and personal care.
As of today, Allenwerod at Pillsbury Manor lus failed to con€ct, at a minin:unr,lhc deticiency al5.2.a
by lriovember 3, 2018. Per interview with facility stali'during thc morning of November 5, 2fll8. by a
Registered Nurse survcyor who is or:silE al the Soullt Burlington cantpus. t'esirlents have not yel
received bills for tlreir roonr, board and personal carc since thc deficiex)y was issued. Furdrer,
Allenwuod at Pillsbury has fniled'to subnrit any POC fcr the de{lcienciss regarding bil}ing residents,
residenl refunds, and r{:sident righls to revicw financial records.
Sanctitirts

Based upon the fbilurc to colrecl at least rxre violation by the date indicated and the failure lo submit
conrprehensive lJlan af'Conection for eacli deficiency identified durirrg the October 3. 201 8,
investigation, tlrc Division is prepnred to impose $anctions in accordanee with 33 V.$.A. $?l I l.

Dicabtlity and Aging Servlces
Licenclng and Protectlon

a

Bllnd and Vteuelly Imparled
Vocadonal Xehabilitstion

 In tlte ntrtice, datecl OctoLrer 15, 2018, that nccomparfed the Oclobel'3, 2018, violatioits, irrcluding the
violation regarding billing, the Division nutified the facilitv that enfor.een:enl renrcdies nray inclutje
suspending adn:issio:rs lb your faciiity in lhe ev*nl tho violations reniained uucolrccted, Furtber, 33
V.S.A. $? I I I (bX3) plovidcs tlrut il the licensing agency rcquires colrcctivc action atcl thc facilily l:as
not correct€d the vinlation by the time specified, as is ihe ease here, ilre licensing agency nray {ake suclr
firrther aclion as il deems appropriate undu'r this section. Fina-lly, Section 4.1 5.c of the Besidcntial Care
Ht;me i,icmsi.ng Rtgulations aullrorizes the imposition of sanctions for fhilure lo reiurn a plan of
c0rrccli\re aelion.
Batt-qr13drni€siel-;
Baseci on ths above, the Divisian of Licensing and Proteclion is impclsing a Brn o* ,{dmissions,
effective upon receipt of this notice" Tl:i.s notice lras been scnl via certified mail, return receipt
requested, lo confirm the date of rer:eipt, No nen, rcsidents mny be adwittcd nftcr thilt thtte.

fte

Ban on Admissions will ccrrlinue until the honre achieves ccrnpliancc with all Rcsidentisl Clare
Honre regulations and submits a cnnrprehensive POC iri response tc) the October 15, 20i 8, letter. A
notif ication will be sent al lhe tinrc the ban is lifted, and the hnme may not admil any rlew rcsidents
until notified by this Division that the bar bas been lifted. This does not apply lo rc-edmissions ol'
residents who currcutly rcsirle at the home at the time of reccipt of this lctler, who requircd a
temporary transfer to another care setting or ther*peufic leavc,

Appeal

You have the right tei appeal this dccision. You nray request a review of lhis decision by contacling the
Ci:mmissioncr of Disabilities, Aging, and lndependent Lir,ing witlrin fifteen (15) dnys u{'the elate *l'
lhis nctice, 'l'o ruquest an appeal r.vith rhe Comntissioner, call (80?) ?41-0353. You may also request a
fair hearing rvith the l"luman Services Board, within thirty (:10) clays alter the date of the
Commissi*ner-'s dr,:cision, or rvilhin thilt3' {30) days after thc date of this notice, by writing to the Hoard
at l4-16 Baldrvin Street, Montpelier. V'1'05633-43t)2 or by calling the Board ar {802) 828-2536.

Sincerely.
.:t

1",,

.

l-,,"t

.. '::

i':

,

llarriela M- Cota, RN
Liccnsing Chief

cc: Stuail

Schun'. General Cnunsel

Sear: Lotrdergan, Slate Long'Ierrn Care Ombudsrnan

Audrerv Wlrite, Licensee
Corporation Service Company, Registered Agent

 ef"{""*- .VERMONT

Acs,xcv on Hu*ren Ssnvrcps
Dr,penrunNT ot" DrsAsrurrrrs, Acrxc aFr lxpprENDENT LrwNc
pi{siort p-!l=lsstsug&rd-l'LLcqlor
I'lC 2 South. 280 State Drive
Wateri'rury V1' 0567 I -2060

l-rliU#Urf ty,dgil. verrr;-turl.cov
Survey and Cerlification VoicellTY (80?) 241-0480
Survey arrd Cerlilication Fax (802) 241-0343
Survey and Certificatinn lteporting Link: (88$) ?00'5330
To Repurl Arlult Abuse: (800) 564-1612

VIA CTRIII'IED MAIL, IIRR
Novernber 6. 2018

Ms, Barbara h,loynan,
Allenwood At l'illslxrry Manor
90 Allen Road
South $urlington, Vl' 05403-7856
ll_e;"J:lrltiSt-slProitosi{.

t

u I rqlqsc

lia

nc

t

jr

r

lrs

I)ear Ms. Moynan
On October 15" 2018, the Division of Liccnsing and Protectiorr {Df.P) sent you the rcsulls olthe
Octobcr 3,2018, sunrcy at your fhcility. ln the Octobel I5,2018, lettcr, DLP required a Plan of
Corrcction {POC) for all ciled deficicncies. DLP also sct a complianee dale of November 3, 2018' fur
all cilect deficiencies. including thc dcficicncy regarding Residential Care Hon:e rcquirenent 5.2.a,
specifically, the lailure lc bill residerrG frrr their room, bcrard and perscinal care.
As of torlay, Allenwood at Pillsbury Manor has failed to correcl, al a miniu:um, the deficiency al 5.2.a
hy November 3, 2018. Per interview with facility stat'f durir:g the morning of Novcmber 5, 2018, by a
Regislered Ntrrse survcyor wlro is orrsite at the Soulir f3ullington canrpus, residents l'rave ncl yet
received bilis lbr llreir roonr, board and personal care since the deficiorey was issued. Furiher,
Allenrryood alPillsbury has failed'to subnrit nny P()C for the det'iciencies regarding billing rcsidents,
rcsidenl relunds, and rcsidenl rigl:ts to revicw financial rccords.

9als:ist$
Based upon the failrrre to correcl at least une violation by lhe date indicated and the failure lo submit a
r:omprehensive PIan of Corrcction for each de{icicncy identificd during the October 3.2018,
investigation, the Division is prepared to impose $anctrons jn accordance with 33 V.S.A. $71 i 1.

Ditabtlity and Aglng Servlces
Llcenslng snd Protectlon

Blind and Vicually Imparied
Vostional Rehrbilitafi on

 Irr the notice, dated October I 5, 2018, that rccompanied the Oetober 3, 1018, violaliorrs, ine luding the

violation r'egarding hilling, the Division noti{led the facility that enfirrcenrerrt rentedies niay irtclude
suspending admissioris 10 your facility in the event the violalions renraincd uncotrccted. Further, 3"1
V.S,A, $71 I I (bX3) prcvides tbut if the licensing agency requires correctivc aclion and tlte facilily has
not correcred the virlation by tlre time specified, as is the case here, 1he licensing agency ruay take such
further aclion as it deems approprinte under this section. Finally, Serlion 4.15.e ol'the "REtlde ntial Car{t
Homc L,iun.ring {le gulations autlrolizes the imposition of sanctions for fhilure to rerum a plan of
corrcclivc action.
Bansn"A"-dltisj:sus

on the abovc, the Division of Licelsing and Protection is imposing a Ban on Admissions,
effectivc upon rcceipt of this notice. This notice ltas been sent via certilied nrail, returu receipt
requested" to confirm fte dale of receipt. llo new residents m*y be ndwltted nfter thnl dale.
Baseel

'fhe llan on Adrnissions will continue until tJre hcrnre achieves colrrplia:ce with all Rcsidential Care
I lonte regulations and submits a conrprehensive POLI iq response 1o the Octrrber 15, 2018, letler. A
notification will be sent at the tin:e the ban is lifted, and llre horne rnay not adrnit any new tesidents
until noiified by this Divisian that tlre ban has been lifted. This does not apply to re-sdmi*sions of
rsnidents who currently reside rl the homc at the tirne of recei;rt of thin lettcr, who required a
tcrnporar1 transfcr to anofher care setting or therapeutic leavc.

Aprcal
You have the riglrt to appeal this dccision. You may rec;uesl a review of this decisiort by contacling lhe
Conmissioner of Disabilities, Aging, and Indeper:dent l.iving within fiftccn ( l5) d$ys of the dale of
this noticc. To requcst an appeal with the Ccmmissioner, call t802) 241-0353. You nray also reqursl a
fair hcaring rvith the Human Serviees Board, within lhirry (30) days after lhc date of thc
Commissioner's decisirln, or willrin thirty (30) days afler the datc of this notice, by writing 1o the Board
ai I 4- l6 Baldrvin Street, Montpelier. V'l 05633-4302 or by cailing the Board at i802) 818-2536.

Sincerely,
.t)
Panrela M. tlota" il,N
I..icensing etrief

Schurr, (ierteral Ccilnsel
Sean L,andergan, Slale Long Terrn Care Ombutisman

cc: Snlart

Andrew White, Lieensee
Corporation Service Company, Registercd Agerrt

 ir-L IIERMONT

Acexcv or Hurrnen Sr,nvrces
I)gplnrntrNT oF Dtsactt,rrrtrs, AclNc anu InoapDNDENT Lrvrxs
in s,*and P rr tJi:sliul
2
South.280
Slatc Drive
IIC

Oiusrslr-o-l-L.$9 nt

Waterirury

Vl'

0567 I -?060

gq
-qUad-4il.,yetttrt n t, v
fiurvey and Cenificatinn Voice/TTY (802) 241-0480
Survey nnd Certification Fax {802} 241-iX43
Survey anrJ Certificatirrn llcprrrring t.ink: (88t ) ?00-533CI
T* Rt-prrt Ailult Abuse: (800) 564.1612

JUp

:

{tt

VIA CERI'IFIED MAIL, RRR
Novenrbel 6, 2018

Ms. llarbara Moynan,
Allenwood At Pillsbury Mnnor
Q0 Allen Rtlad
South Burlington, V'f 05403-7856
Ii c -l-lltftjcc"_Ul' Plr1prtSl l. lt t

I

rrt I rt

rs*

$a

Ur,:t

i

g15

Dear Ms. Molnan
L)n October 15, 201 8, the Division of Licensing and Protection (Dl,P) sent you the results of lhe
Orto,ber 3o 2018, survey al your facility. ln lhe Ostober l5, 20l8, letter, DI.P required a Plan of
Correction (POC) tbr all cited deficiencies. DLP also sct a compliance date of Novcmber J, 2018, lbr
all {ritcd dellcierc.ies, including thc deficiericy regarding ltesidential Carc tlein:e requirenrenl 5,2.a,
specifically, the l?rilure to bill resitletts for lheir room, board and persor:al care.

As of loday" Allenwood at Pillsbury Manor has failed to ecrrcct, al a mininrum, lhe rleficicncy at 5.2.a
by lticvember 3, ?01 8" Per inlen'iew with facility staffduring the nroming of November 5, 2018, by a
Registered Nurse sllrveyor who is onsile at the South Burlington can,tpus, residents have not yet
received bills for their roont, baard and pei*onal carc since the deficiency was issucd, Furlher,
AJlenwood at Pillsbury has fuiled'to subnrit any P{)C for the deficiencies rcgarding Lrilling residents.
resident re{irtttis, and residcrnt lights 1o review financial rccords.

$*!strs$
Based upan the failure to correcl al least otrc violation by the date indicated and the faiiure to submit a
conrplelrensive Plan of Corrcction for each deficicncy identified during the October 3. 2018,
irrvestigation, the Division is prepared to impose sanctions in accotdance with 33 V.S.A. $7ll l.

Dlcablllty and Aglng $ervicec
Licenrlng and Protec6on

Blind and Visually tmparled
Vocetcnal Rchabilitedon

 In thc rotice, datcclOctnber l-i.2018,:.hat acconr;rarried the October3,2tll8, violations, including tlrr:
violalion regarding bil!irrg, the Divisian notil'ied tlre facility tl:al enlbrccr:rent letnedies nray iltclucle
suspending adurissions to your facility in the event the virrJations rurraincd uncolrccted, Iurther, 3li
V.S.A: $ 7l 1 1 {bi{3) p: ovides that if the iieensirig agency requires couectjvc aclion and tlre facility has
JXll conected llic riolation by the tirtre specilied. as is the case here, tlre licensing agency rnay {ake such
further actiorr as it deems appropriate urreler this seclion. I,-inally, Seclion 4.15.c of the nesie/rntial L*re
Honte l"icex"ring Regufutions aulhorizes the impositior.r af saneticns for lbilure to retu:'n a plan of
corrcclivc action.

BeLqUAdtrlr$ts:lq
llased on the abuvc, the Division of Licensing and Prolection is imposirrg a Ban on Adnrissions,
efftctive upon r*ccipt erf this nofice. This notise hns been scnl via cedified nrail, relurn receipl
rcquested, to eonfimr the date ol rcceipt. No nen: residen$ mny be adn$tted nfter thnt dale.
'l-he Ban on Admissions will continue until tlre home achievcs troulpliance ra,ith all Rcsidcntial Cale
Honre regulations and subnlits a cerntprebensive POC in response ts ihc Octaber 15. 2018, leller. A
rtolification will be sent a1 the tin:c the ban is lified, and the home may not admit any new :'esiden(s
until nolitietJ by lhis Division thal tl:e han lras been lilicd. This does not apply to rc-ndmissions af
residents who eurrently reside at th€ horne at the time of receipt of lhis letter, r'ho required a
temporary transfer to another csre sctting or therapeutic leave.

Anoeal
You lrave the right to appcal this dccision, You n:ay rcque.sl a review of this decision by eontacting the
Ccnrmissioner of Disabilities. Ap,ing, and Indcpendcnt Living witliin Iitteen (15) clays of the date nf
tiris notice. To request an appeal u'ith the Cammissioner, call (8tj2) 241-0353. You may also requesl a
{'air hearing with thc l-l,uman Services Bonrd, within thirty (30) days after the date uf the
Con:n:issiairer's decisiorr, or wilhin thirtl, f 30) days afler tlre dntr: of this notice, by writing 1o the Boaid
at l4-16 Baldrvin Street, Mon:pelier, V"l'{i5613-4302 or by calling the lJoard at (80?} 828-2536.

Sincerely.

il.
Parnela M. Cua, ItN

l-icensing Chief

re

:

Stuart Schurr. Ger:eral Counsel

Sean Londergan, Slate Long'l'crin Care Ombudsrnan

Aadrew Whitc. Liccnsee
Coryroration Selrrice ( ionrpany, lLegistcrcd Agent

 Weiss, Bessie
Frtrn:
Sent

Tuesday, November 06, 2018 2;31 PM

To:
Subject:

Weiss, Bessie
FW: Urgent Need to Address Food Shortage

lmportance:

High

Hutt Monica

From: Hutt, Monica
Sent: Tuesday, November 0O 2018 1:37 pM
To:'awhite@elcm.com' <awhite@elcm.com>
Cc: Kristin €louser {Kristin.Clouser@vermont.gov} <Kristin.Clouser@vermont.gov>;
Schurr, stuart
<stuart.schurr@vermont.gov>; cota, pamela <pamela.cota@vermont.gov>
Subject: Urgent Need to Address Food Shortage

lmportance: Hith
Dear Mr. White,
As you are probably aware, nurse surveyors from the Department of Disabilities,
Aging and lndependent living,s Division
of Llgensing and Protection are currently on site at bolh the Pillsbury Manor-South and
the Rllenwood at pillsbury
Manor properties. The purpose of this visit is to investigate complaints and
determine whether the facilities are in
compliance with the Residential Care Home Regulstions. ln the course of this
survey, Department stalf have learned not
only that food supplies are critically low but also that Reinhart Food Seivice
has ceaied its food deliveries to these

facilitiesasaresultoftheamountspastdueonthisaccount. Thepurposeofthiscorrespondencelstonotiiryouofthe
imminent need for food at these facilities and, as such, to stress upon you the urgenry
of issuing payment to Reinhart
and placing an order for food delivery today.
Your immediate attention to this matter is essential, Kindly acknowledge your
receipt of thls message and indicate
time by which you will rectifli this situation.
5incerely,

1

a

 Weisg Bessie
From:

Weiss, Bessie
Tuesday, November 06, 2018 2:49 PM

Sent:

To:
Subject:

Hutt, Monica
Rt: UrEent Need to Address Food Shortage

Thank Youl

From: Hutt, Mo nica <Monica.

H

utt@vermo nt.gov>

Sent: Tuesday, November 06, 2018 2:45 PM
To: Weiss, Bessie <Bessie.Weiss@vermont.gov>; Clouser, Kristin <Krlstin.Clouser@vermont.gov>;Schurr, Stuart
<Stuart.Schurr@vermont,gov>
SubJect: FW: Urgent Need to Address Food Shortage

FYI

Monica Caserta Hutt, Comrnissioner
Vermont Department of Dlsabllltles, Aging and lndependent Living
Commissioner's Offlce
HC 2 South
280 State Drive
Waterbury, VT 05671-2020

Telephone; 842.241.240 t
E.mall: monica,hutt@verment.eov
http://www.da Lve rmo nt,Fovl
i

The mission af the Vermont Deportment of Otsoblllties, Aging and lndependent Living is to muke Vermont the best stote
in which to grow old or to tive with o disability - with dignity, respect and independence.

From: postmaster@elcrn,com <postmaster@elcm.c >
Sent: Tuesday, Novernber 05, 2018 1:37 PM
To: Hutt, Monica
SubJect: Delivered: Urgent Need to Address Food Shortage

Your message has been delivered to the following rccipients:
awhite@elcm.com (awhite@elcm.mm)
Subject: Urgent Need to Address Food Shortage

1

 Monica caserta Hutt
Commissioner

Monica Caserta Hutt, Commlssloner
Vermont Department of Dlsabllltles, ASlng and lndependent Livlng
Commiseloner's Offlce
H€ 2 South
280 State Drlve
Waterbu ry, VT 05671-2020
Telephone: 8A2,24L.24OI
E.mail: r-nonica. hutt@vermqnt.gov

httn:llwww.dail.vermo nt:eovl
The mission of the Vermont Deportment af Disabilities, Aging and lndependent Living is to make Vermontthe besf sfote
in which to grow old or to live with a disability - with dignity, respect and independence

2

 v,l,

j*i"','i''i

ii i';l"t'

stetErCI,fo:r&nrrdOur
SUPERIOR COURT
WASHINGTON UNIT

t$i0 l{Ot,

-

J

DIVISION
A -ctr\ilL
bbbrur No,dl r-//-

/   */""t

)
)

Commiseioner of the
Depa4ment of Disabilities, Aging and
Independent Living,

Plaintiff
v.

rtd I l:
)

)
)
)

Homestead at Pi[sbury;
Pillsbury Manor - South;
Allenwood at Pillsbury Manor;
ELCM Allenwood Management LLC
Defendants

)
)
)
)
)

EMERGENCY MOTION FOR THE HT PARTE APPOIN?MENT OFA
TEMPORARY BECEIYEN
NOW COMES the State of Yermont, Commissioner of the Department of

Disabilities, Aging, and Independent Living (hereinafter "DAIL" or "the licensing
agency''), by and through Attorney General Thomas J. Donovan, anil hereby moves

the Honorable Cowt pureuant to 33 V.S.A. $7203&X1) and (2) to appoint er parte a

tenporary receiver to operate the three Defendant residential care facilitiee in St.
Albans and South Burlington, Vermont. AfEdavits, attached. herein, set forth the
factual baeis upon which the Commissioner relies upon in making this motion.

Exhibits A-G.
Aa described in the affidavits, the fgilowing situation and practices at the

facility present imminent danger of serious physical or mental harm to residente

 that must be remedied immediately to ensure the health, safety, and welfare of the
residente:

1. The facilitiee have only a two-day supply of food due to the owner'e fiailure to
pay the food vendors. See Exhibit G. The potential to run out of food ie
compounded by the fact that the facilities have only a emall amount of petty
cash on-han d,.

Id. Stalf communication to corporate,

as well as

communication by DAIL, has, to date, failed to result in payments.

2.

There are a total of 24? people living in the Pillsbury facilities, 102 sf whom

require tevel

III residential care, which meane they require "personal care,

defined as assistance with meals, dressing, movement, bathing, grooming, or
other personal needs, or general supervieion of physical or mental weil-heing,

including nursing overview and medication management." 33 V.S.A.

S

?102(t0XA). The other 145 residents are currently appropriate for
independent iiving. Those in residential care are entitled to receive all of

their meals at the facility and those in independent living are generally
entitled to receive one meal a day.

3.

The owner of the facilities is ELCM Pillsbury Management LLC, which is

solely owned and managed by Andrew White out of Dallas, TX. Mr. White
suddenly, and without notice, elosed the bank account that covered the

Vermont facilities in February 2018. See Exhibit A. Since then residents have
not been invoiced and their rent checks remain undeposited. For the same
reasons, paymehts to vendors became sporadic and untimely,Id.

2

 4. Staffmembers

ar€ reeigning and not being replaced, r'esulting in dangerous

staff shortages. Nurses are covering multiple positions at once, and
sometimes there is only one charge nur$e to cover two buildings and there

have also been instances of nurses working 100-hour weeke. Id,.
13-110-009, at 5.11

see

olso CVR

and "Complaint and Application for Appointment of

Receiver" at paragraph 17.

5. Staff shortages have likely contributed

to instances of inadequate care,

. including: failure to report an accidental patient death to the lieensing
agency, failure to properly monitor residents to prevent falls, and failule to

monitor the well-being and hygiene of a sick resident resulting in her need for
emergency care. See Exhibits L, M, N, and O.

6" Ttre above situation

tregan eight months ago and has gtown exponentially

worge in recent weeks.

It

is causing residents and staff great anxiety and

emotional distress. In the last month the licensing agency has banned
admissions in two of the facilities for failing to correct cited violations.

See

Exhibits P, Q. Every day, residents and their families are arxioug about the
potential for innminent shut-down resulting in the sudden loss of housing and
care. Sae Exhibits D, E.

7. During this period of instability DAIL, the Attorney

General's Office, and the

State Long-Term Care Ombudsman have dernanded that Mr. White prnvide
assurances, information, and records that the facilities are indeed solvent

3

 and capable of meeting required health and safety standarde, but he has
repeatedly ignored or rebuffed all of these inquiries. Exhibits B, K, J, and R.

8.

As further illustrated in the attached "Complaint and Application for
Appointment of Receiver' and exhibits, incorporated herein as if set forth

fully below, a temporary receiver is necessary in order to ensure the health,
safety, and welfare of the residents of the facility.

For the reagons stated absve the Department requires the following relief:

l-.

The immediate appointment of Douglas J. Wolinsk)r, Es{., of Primer, Piper,
Eggleston & Cramer, P"C.fo assum€ full responsibility for the operation and
management of Homestead at Pillsbury, Pillsbury Manor South, and

Allenwood at Pillsbury Manor. The order should provide the temporary
receiver with all of the power$ and, responsibilities provided at 33 V.S.A.
$7207 (b).

Signed and dated at W'aterbury, Verrpont

this

day of November, 2018-

Respectfully submitted,
STATE OF \TERMONT,
MONICA CASERTA HUTT
COMMISSIONER, DEPARTMENT OF
DISABILITIES, AGING,
AND INDEPENDENT TIVING
through counsel
THOMAS J. DONOVAN, JR.
ATTORNEY GENERAL

4

 r/t

By:

M-u,otl, UL//ltt-<
Bessie

l{eiss

Aseistant Attorney General
HC 2 South
280 State Drive
Waterbury, VT 05671'20201
{s02) 241-0194
ERN: 4141

5

 STATE OF VEBMONT
SUPERIOR COURT
WASHINGTON UNIT
Commissioner of the
Department of Disabilities, Aging, and
Independ.ent Living,

Plainii,ff
v.

Homestead at PillsburY;
Pillsbury Manor - South;
Allenwood at PillsburY Manor,
Defend,ants

)
)

CIVIL DIVISION
DOCKET NO.

)
)
)
)
)
)
)
)
)
)
)
)
)

STATE'S LIST OF RECOMIUIENDED NECEIVERS
NOW COMES Monica Caeerta Hutt, Commissioner of the Department of

Dieabilities, Aging, and Independent Living, and pursuant to 33 V.S.A. $ 7205,
submits the following list, in no particular otder, of recommended persons to
coneid.er for appointment ae the receiver in the above-captioned action"

Jeff Sande, CTP, MBA
Dorset Partners, LLC
P.O. Box 67 Dorset, VT 05251
802.867.2458
Douglas J. Wolinsky. Eeq.

Shareholder
Primer, Piper, Eggleston & Cramer, P.C.
PO Box 1489 150 S Champlain St 1550 Winiston Road
Burlington, VT 05402-1489
802.864.0880
Suzanne Koeniq
Presid.ent, Founder
SAK Management Services LLC
One Northfield Plaza, Suite 210

 Northfield, IL 60093
847.446.8400

A r6oum6 or preeentation of professional qualifications for each is attached
herewith,
Signed and dated at lryaterbury, Vermont

this {'fu

day of November, g018'

ResPectfu llY submitted,

STATE OF VERI\{OhIT,
MONICA CASERTA HUTT
COMMISSIONER, DEPART\{ENT OF
DISABILITIES, AGING,

AND I}{DEPENDENT LIVING
through counsel
THOMAS J. DONOVAN, JR.
ATTORNEY GENERAL

By:
Beesie Weise

Aesistant Attorney Genqral
HC 2 South
280 State Drive
Waterbury, VT 056?1'20201
(802) 241-07s4
ERN:4141

 Douehs J. Wolinskv is a shareholder of Primmer Pipcr Eggleston & Cramer PC, a
regional law firm with offices in Burlington and Montpelier, Vermont; Manchester,
Littleton, and Portsmouth, New Hampshire; Camden, Maine; and Washington, D.C' Mr.
Wolinsky practices in the areas of intellectual property, banking, fin&nce, bankruptcy,
and creditors' rights. He currently serves on the Panel of Chapter 7 Trustees for the
Disrict of Vermont and the Northem Districl of New York. He has also seryed as a
Chapter 1l Trustee in cases such as The Lawrence Group, Ine.,in the Northem District of
New York, *nd American Paper Mills af w, Inc.,in the District of Vermont.

Mr. Wolinsky is a member of Primmer's financial services and banking practice. He
represents both lenders and borrowers in commercial, retail finance and general banking
matters, including foreclOsures! restfucturings, workouts, bankruptcies, and loan
originations. Mr. Wolinsky represents lenders in both commercial and consurner matters.
primmer counts among its lender clients local, regional, national, and international
financial institutions. Primmer also advises its financial clients with respect to their
corporate and regulatory matters.

Mr. Wolinsky is a member of the Amsrican Intellectual Property Law Association, the
Vermont Bar Association Intellectual Property Committee, the American Bankruptcy
lnstitute, the Tumaround Management Association, the National Association of
Bankruptcy Trustees, and the Vermont Bar Association Bankruptcy Law Cornmittee. He
is a pasl Chair of the Vermont Bar Association Bankruptry Law Committeg and is
currently on the Capital Region Bankruptcy Bar Association's Board of Directors.
is recognized among the The Best Lawyers in Amevica 2017. He is also
listed in the 2018 edition of New England Supev I awyers. Mr. Wolinsky is a Martindale
H. Brown etal. Banl+ruptcy
Flubble AV rated a$orney. He is a contributor ro

Mr. Wolinsky

I

Exemption Manual, Wests Banlo"uptcy Series.2003 through 2017 Editions.

Mr. Wolinsky is a member of the {irm's board of directors. He is admitted

to practice in

Vermont and New York.
Recent speaking engagements include:
Co-presenter, "The Ramifications and Effects of Collusive Bidding in Bankruptcy
Sales and the Chapter ? Trustee's Remedies"; National Association of
Bankruptcy Trustees; 2011 Spring Seminar
Co-presenter, "What is Good Faith? Chapter 7, I I and 12 Comparison"; Capital
Region Bankruptcy Bar Association 18th Annual Bankruptcy Conferense;

.
.

r
.

November 8, 2013

Joint CLE Coordinator for Capital Region Bankruptcy Bar Association and
Vermont Bar Association;March 27,2A15

A further dgscription ofthe firm's practice
website www.primmer,com.

3121589.1

areas and professionals can be found at the

 rset Partners

LLc

Jeff Sands, CTP, MBA
of
Jeff is a Certified Turnaround Practitioner and winner of the TMA's 2017 Turnaround
entailed
This
the year Award for a Vermont $10 million aerospace machining business.
dealing with the deceased owners wife, the union, the FBI who were investigating
possible fraud as well as the employees, customers and vendors.
In 2018 he, again, earned the Turnaround of the Year Award, this tiine for a $200 million
pulp and paper mill in northern Canada. Successfully dealing with 12 separate tribal
ieaders in a remote location was his greatest challenge. The company was losing money'
had lost it's major account and was facing bankruptry. Today the company is profitable
and the tribes are happy to be gainfully employed'
Currently Jeff is working on transforming a copper tubing mill and a light pole
manufacturer, Both were shut down due to financial constraints and both are fully
functioning at a profitable level.
a
Since 2002, Jeff has transformed dozens of businesses in dozens of industries and has

reputation for taking on the very toughest situations. His reputation among financial
institutions in Vermont and the Albany capital region is without peer.
In addition to corporate turnarounds, Jeff is known widely for his ability to attain top
dollar in the sale of distressed businesses, maximizing going concern and strategic.
values. These distressed sales deliver many times more value than an auction to creditors
while also saving jobs, rwitalizing the local economy and providing a dignified exit to

the debtors
Jeff earned his BS in Economics at Hobart College and his MBA from Alaska Pacific
University. He currently serves on the board of 3 private cornpanies and one community
organizaiion. He lives in Dorset Vermont is married with three children and when free
time allows enjoys multiple outdoor sports. Jeff's wife is a practicing RN in Manchester

Vermont.
Jeff recently authored Corporote Turnoround Artistry,
will be published by J. Wiley & Sons in 2019.

Fk

AnyBustness in

fiADoys which

 David Sands
Dave has more than 35 years of hands-on experience in senior management. He gained
further experience as an operational/productivity consultant in such diverse areas as
hospital restructuring/consolidation. retail, service industries and small to medium sized
manufacturing. Dave's entrepreneurial background includes the startup and running of a
dornestic manufacturing business with over 250 employees selling nationwide.
In the City of St Louis, Dave negotiated a contract and led a team organizing, planning
and implementing the consolidation of two city hospitals into one. This impacted

training of all levels of staff including Doctors, nurses, pharmary, administrative as well as
outside support personnel. The consolidation was successful resulting in improved
patient care at a significant cost saving.
A nursing home in Vermont was distress financially. Dave conducted an assessment and
provided a plan to the board to irnprove collections, replace the CEO and to better train
the care providers.
As a board member and finance committee mernber of the VNA (Visiting Nurses
Association) of Southwest Vermont, Dave has offered his services for the past 5 years.

During this time we have successfully purchased the VNA's of Manchester and
Bennington improving the level of care (Awarded TOP 100 status nationally) and

improving profitability,
Recent Turnaround engagernentS include Interim CEO of a multi-national rnanufacturer
while guiding them through a CH #11, the Turnaround and sale of a plastic molding
cornpany, the turnaround of a steel fabricator, {inancial restructuring of a funeral home,

strategic planning for a family owned business in Vermont struggling with multi
generations in the business, a multi state trucking company and as a financial monitor of
a multi state bakery.
Dave graduated from Syracuse Univ. with a major in Advertising/Marketing. He also
completed graduate studies in Finance, M&A and Business Administration from

 Syracuse Case Western Reserve and Hofstra. He has served on numerous private
company Boards, community Boards and the Board of the Tulane Family Business Forum.
Dave lives in Dorset Vermont with his wifie of 5O+years enjoying grandchildren, biking,
skiing and snowshoeing. Dave also coaches boy's youth lacrosse and has served as the
president of the Equinox Lacrosse Assoc,

P.O, BOX 67

/

DORSFI;

W

05251

l

8A2-867 -?456 1 www.dorsetpartners.com

 Statement of Qual ifications

PREPARED FOR

Ms, Bassle Welss
Office of tlre Attorney General
State of Vermont
Re:

Vermont ReceivershiP

 SAK Management Services, LLC

2

SAK OVERV EW A OPERATING PHILOSOPI{Y

Experienced Healthcare Profess lonals
SAK Management Seruices LLC ('SAK') is a highly skilled, long-term care management
and mnsulting services company, specializing in the continuum of care process
throughout tndUniteO States. With a broad background in Continuing Care Retirement
Comriunities, Nursing Facilities, lndependent Living Facilities, Congregate Living
Facilities, Supervisory Living Facilities and Assisted Living Facilities, our dynamic team
piovides'leadership iapanililies in the Seniors Housing & Care lndustry. We offer proven
proficiency in maximizing financial return and cash flow, while maintaining the highest
itandardg of quality cari Snf and its affiliates have been providing managernent and
support services in the long-term care field for over 30 years'

SAK's Resource CaPabilities
SAK's operating philosophy is premised on the belief that the Seniors Housing & Care
lndustry'is a 'hlnds on approach" and market sensitive business, principally dependent
talent....Moreover, the ever-increasing
upon the resoufce capa'nitities of facility-based
-specialized
skills, both in terms of financial
cirallenges of our industry command
r"n"gjment as well as clinical care capabilities to achieve maximum levels of operating.
perforirance and qualig assurance. Our speclalized service capabilities_ are designed
i,vitn a 'bottom-up' philosophy, promoting the optimal integration of finance and
operations, while iupporting the practice and development of these combined skill seF
in key people, locallY situated.

Speclalized Turnaround Expertiee

SAK specializes in operating nursing facilities that require strategic re-direction and
turnaround management services. Currently, all of the facilities owned, operated or
serviceO by SAK a]re current in proper$ obligations, have achieved operating stability and

are in fulliompliance with applicable slate and Federal regulations. SAK's associates
have over 2b0 years collective experience in all phases of long-term care operations, and
have spent a iarge portion of their long-term care careers in turnaround situations,
rescuing troub led facilities.

J:/State of Vcrmont/Slatsment of Qualifications

 SAK Management Services, LLC.

3

SAK'g Mlssion

Our aim and purpose is to improve the financial performance of the facilities while
maintaining the highest practicable levels of care and service to the residents.

sAK PROFESSIONAL SERVICFS PROFILE
Gensus Develooment
Census development is an indispensable part of facility management. SAKs philosophy
is that census development includes both increasing occupancy and improving the
resident payor mix. To that end, SAK has developed both internaland external programs,
Within the facility, SAK enhances staff skills with training in guest relations, sensitivity
workshops, interaction with referral sources, and image creation. ln addition, SAK woks
aggressively with Medicaid programs, hospitals, discharge planners, physicians'groups,
managed care plans, socialwod<ers, and case managers to increase image, reputaiion,
recognition, and ultimately, referrals,

Finance
The abilig to manage finance and personnel issues is pivotalto the survival of any care
facility. As experienced administrators, rnanager$ and owners, SAK and its team are
seasoned veterans at improving a tacility's bottom line. The financial services provided
by SAK are designed to provide both reporting on the status and progress of the facilities
and for use as management tools to direct continuing improvements. Hiring practices and
employee retention play a key role in cost control and sensible use of facility dollars. SAK
will negotiate favorahle payment terms with vendors by contractual purchasing.

$AK oversees all financial decision-making at the facility lBvel and provides monthly,

quarterly, and annualaccounting to ciients. SAK maximizes facility income by impacting
on and working with State Medicaid systems, enabling each resident to benefit from the
optimal Medicare reimbursement, meeting managed care expectations with utilization at
fair and compensatory rate, establishing budgets and controlling budgetary
performance, asset management and cash flow management. ln addition, SAK provides
staff with the training necessary to effectively run the financial side of a facili$ with
emphasis on the following areasr cost control, third party reimbursement, resident trust
funds, human resource management, accounts receivable, accounts payable, insurance,
cost reports, unemployment insurance, employer and general tax returns, workers'
compensation and payroll preparation.

a

Reoulatorv Gomollance
SAK provides clear and comprehensive policies and procedures, extensive in-service
training, close monitoring, broad-based and repeated training in systems for selective

J:/Statc

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Vermont/Stotelhen{ ol Qualifi cations

 SAK Managernent Services,

LLC.

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living and staff-orientation related to the care of the residents" $AK will assist the facilities
in 1j dealings with regulatory agencies and will represent the facility with such agencies
upon requeit of the-facility. Cbre systems are.designed and implemented to insure
ibpropriate documentation and reporting to meet regulalory requirements as wellas to
steady flow of meaningful information to Management and all constituent

pi*ia!

interests.

Nursino Services
Our staff provides clinicat training in recognizing and.assessing each resident's nursing
needs with the aim of providing t[e nighest quali$ of life at the highest practicable level.
SAK p.rronnel have supervisbd cafe at all levels in the continuum from sub-acute to
supp[rtiuu living servicei. We emphasize leam trainin-g 1P work concept which focuses
on:'activities oi daily living, clinical assessment, infection contrsl, continuous quality
improvement, care ptanningln4Ds, charting to assure reimbursement, and resident and
family interaction, Ciur team training assures excellent daily care, but reduces staff callins, iecreases or eliminates the need for expensive agency personnel, and creates
comprehensive regulatory cornpliance for our residents'

Rehabilitation
SAK believes that it is the facility's responsibility to ensure that each resident functions at
his/her rnaximum ability. to inat end, SAK designs and irnplements routine' and
restorative and rehabilitative programs with three goals: The program must keep
residents functioning at their maximum capability, it must be easy for staff to understand
and execute, and it must deliver eare at the lowest possible cost.

Dietarv
sAK believes that staff should provide nutritious and appealing meals in an environment
io promote a positive and fulfiiling dining experience for.the resident. SAK has created
dining prograrns that successfully achieve this goal. Our dieticians also train staff to meet
each-resid-ents medically prescribed diet and speciallikes by creating tastefully satisfying
meals.

SocialSewice
SAK believes that any social service departnent must be a resource for the resident, the
resiOenfs family, anC ttre facility. SAK's Social Se{vice programs include resident
couniering, family counseling, counseling regarding advance directives, resident financial
pl"nning,lssistance with obtaining Medicaid eligibility, and assistance in interacting with
care providers, ln addition, if eventual discharge is to home or a lower level of

ffi;dd

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 SAK Management Services, LLC

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care is feasible, SAK's Social Seruice programs begin the planning and preparation for
discharge upon admission, making the discharge process easier for both the resident and
his or her family.

Psvchosoclal Proqrams
The most challenging residents in continuum of care environments are those with
permanent cognitive deficits. Often, staff fails to work effectively with these residents
because they irave not been adequately trained. That failure is reflected both in the

resident's qubtity of life, and in regulatory deficiencies. SAK has developed programs t9.
assist residents to realize their full potential. Those programs are combined with staff
training concentrating on understanding cognitive deficits, connecting with those who
have Juch deficits, Jnd effectively helping residents with their environment and their
health issues.

Actlvities
SAK believes that an active and creative activily program is essentialto the quality of life
for residents. SAK develops diverse programs that deliver entertaining and educational
variety, which keep residents involved in the world around them. SAK's programs
enhance a resident's self-image and create a more satisffing quality of life-

Housekeepinq

The hallmark of an SAK managed facility is superior cleanliness and safety. SAK

incorporates its housekeeping staff into infection control programs, quality of life training,
and regulatory compliance frocedures. SAK believes that a housekeeping staff that
knows ihey perform a critical function elevates job performance'

Maintenance
The ability to maintain all essential mechanical, electrical, and resident care equiprnent in
a safe cind16n is basic to SAK's management philosophy. SAK has the technical
knowledge and skill to evaluaie and maintain the physical.plant of a facjlily ln addition,
SAf proiiCes educational in-seMce and training to its maintenance staff that motivates
staff io maintain a safe, secure and aesthetically pleasing environment for residents.

J:/State cf Vermont/Slalement of Qualificstions

 SAK Management Services, LLC.

Representative Experience

6

- Recelvershlns

Court Appointed Full Receiver
6 Slrilteil lVursing Facilities, ranging from 92 to 251 licensed beds
Marseilles, Morton, Peorta Heights, Princeton, and Springfield' lL
ln November 2016, Suzanne Koenig was appointed. as Receiver for six nursing homes
in central lllinois. Concurently, Central lllinois Management Services ("ClMS"), an
affiliate of SAK Management Servicee, assumed management of these facilities. These
six homes had been experiencing financialdifficulty, and were placed in receivership as
an atternative to bankrJptcy action. Ms. Koenig and CIMS worked diligently to maintain
facility operations while preserving assets and maximizing value for allcreditors'
Within 60 days of engagement, CIMS took the following actions to provide an
opportunity to improve the financial operations of the six receivership homes:

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lnstituted a marketing/business development function, rneeting with area hospitals
and other referral sources to improve the homes' payor mix and improve revenue.
Established census goals at each nursing home, lracking the results in comparison to
the census goal.
Eliminated risage of nursing agencies by ineentivizing current employees to work shifts
and hiring additional staff to fill in open positions.
Revised lhe nursing and CNA staffing schedule and eliminated unnecessary positionsin ag departments Io improve efficiency while maintaining or improving standards of
resident care.
participated in collective bargaining discussions for employee wage and benefits'
Contracted with vendors with which ,SAK had prior relationships, thereby reducing
costs and allowing for extended payment terms.
Created a "key faltor" report for each facility, outlining certain operating indicators for
the use of the oPerations teams.
Created a financial budget, which the COO and her staff reviewed with each nursing
home administrator at the end of each month'
After one year, the court determined that the receivership had performed its function
and the Lessor of these facilities contracted with a new lessee to lease and operate
these homes.

Court-Appointed Fu Il Receiver
66-Bed Medicare SNF
Qak Park, lL
Ms. Koenig was appointed as financial receiver by the Circuit Court of Cook Coun$,
lllinois, for-a O6-bed-SNF located in Oak Park, lllinois, and was subsequently appointed
as Fuli Receiver. Ms. Koenig's responsibilities included full operational and managerial
oversight for the facility. Under Ms. Koenig's steady guiding hand, occupancy, rose in the
revenue tripied in six months. Ms. Koenig
first ye-ar,
-SnX operations itabilized, and Mediiare
creditors and stabilized staff and market
with
conducted lriendly negotiations
anO

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influences, while successfully assisting the lender to complete a sale of the property and
operations.
Courl-Appotnted Full Receiver
104-untt Aselsted Llvlng Facility
North Canton, QH

SAK Management-Ohio, LLC, through Suzanne Koenig, had been court-appointed as the
Receiver in the Court of Common Pleas Stark County, Ohio, with powers to include full
operational and management responsibilities of a 1A4 Unit ALF located in North Canton,
Ohio.
Cou rt-Ap p oi nted F ul, R*elver
96 8ed Skilled Nursing FacilitY

Amboy,lllinois
Suzanne Koenig of SAK had been court-appointed as the Full Receiver in the Circuit
Court of the Fifteenth Judicial Circuit, Lee County, lllinois for a 96 bed Skilled Nursing
Facility, located in Amboy, lllinois.
Suzanne Koenig was cour-.. appointed as the Receiver of the Borrower and all mortgaged
premi$es of the Real Estate, and all personal property; equipment, fixtures, privileges,
iicenses attached or belonging to said mortgage premises all rents, income, issues profits
and rights attached and leases derived from said premises, or collateral. Suzanne
oversaw allfinancial and business transactions for the continuing operation of a 120 bed
skilled nursing facility including Medicare and Medicaid Billing, Accounts Payahle,
Accounts Receivable, Collections and general upkeep of the prernises.
SAK, as the manager, developed and implemented cost containment initiatives in areas
such as payrolt and labor management; purchasing practices and vendor relations
management; materials and supplies management; established budgets and controlled
budgetary performance, asset rnanagement and cash flow management, insurances
administration and risk rnanagement. The FinancialServices provided by SAK improved
both reporting on the status and progress of the facility to the courts and for use as
mdnagement tools to direct continuing improvements at the facility level.

Court-Appointed Financial Receiver
1A unitslstudios and 18 one-bedraom uni/a Senior Supportive Living Facility

Morris,lllinois
Suzanne Koenig of SAK had been court-appointed as the Financial Receiver in the Circuit
Court of the Thirteenth Judicial Circuit, Grundy Coun$, lllinois for a Senior Supportive
Living Facility with 40 uniUstudios and 18 one-bedroom units, located in Morris, lllinois.

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Cout*Appointed Financial R*eiver
120-hed shilled nurcing facilitY
Swansea, llllnois
Suzanne Koenig was court- appointed as the Financial Receiver of the Borrower and all
rnortgaged prernises of the.Real Estate, and all personal pr.opertf equipment, fixtures,
privilEges, licenses attached or belonging to said mortgage premises all rents, income,
issueJprotits and rights attached and leases derived from said prernises, or collateral'
Suzanne oversaw aiifinancial and business transactions for the continuing operation of
a 120 bed skilled nursing facilfty including Medicare and Medicaid Billing, Accounts
payable, Accounts Receivable, Collections and general upkeep of the premises.

SAK developed and implemented cost contiainment initiatives in areas such as payroll
and labor managernent; purchasing practices and vendor relations rnanagement;
materials and su-pplies managernent; estrablished budgets and controlled budgetary
performance, assei management and cash flow management, insurances administration
and risk rnanagement. The Financial Services provided by SAK improved both reporting
on the status Jnd progress of the facility to the courts and for use as management tools
to direct continuing improvements at the facility level.
Natlonal Expsrlence

-

other roles

eperational Consultant Hired al Reguesf of Secured Credltor Group 'Two 6CRCs
148 Skilled Nursing Beds
4l Sktlled Memory SuPPort Beds
118 Personal Care Units
20 Personal Care Memory Support Units
Ss lndapendent Living Patto Homes
322 lndependent LMng APartments
Allegheny County, PA
SAK was engaged to conduct an operational assessment associated with perf,ormance
improvementl operational efficiency, and improved quality of care. The evaluation of all
departments promoted opportunities for revenue enhancement, cost containment and
quality assurance initiatives for the two campuses.

All reports were reviewed with the leadership team and the Board of Directors. Specific
recommendations were devetoped to enhance day{o-day operations in each department
including in-service training, survey preparedness, QA assessments and operational
improvement.

SAK identified, implemented and improved overall operating results in excess of $2
Million and dramatically strengthened the operating ratio for both campuses.

A key factor report was irnplernented that reported census fluctuations and departmental
houri per day on a weekly basis. A dollar impact report accompanied the key factor report,

J:/Statc of VcnnondStaterncnt of Qualificotions

 SAK Management Services, LLC.

I

which tracked the cumulative favorable financial impact of revenue enhancements and
savings initiatives by major line item improvement over specified periods.
Revenue enhancements included but not limited to:

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a

Expanded levels of care based on acuity of patients enabled the facility to increase
revenue.
The Medicaid rate was increased significantly with an improved Medicaid Case Mix
lndex, which was ba$ed on actual care delivered.
Enhan'ced marketing strategies for the skilled nursing facility increased the Medicare
and Managed Care payor mix.

Expense reductions included but not limited to:

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Eliminated nursing agency usage by incentivizing current employees to work shifts,
which reduced significant stafiing costs.
Negotiated with key vendors over contractual terms to reduce pricing and overall
terms.
Reduced supply costs by implementing group purchasing practices and procedures.

Reduced certain employee benefits while still staying focused

to an overall

commitment for employees
Reduced workers'compensation expense by implementing strengthened policies and
procedures combined with disciplined and consistent followthrough by leadership.

Flnanclal Support Serulces
SAK provided significant focus in a number of financial areas including but not limited to:
a

a

a

a

a

Reviewed accounts receivable write offs and implemented policies and procedures to
minimize exposure write offs for non-controllable issues
Revised monthly financial statement package to enable easier consumption by
external parties utilizing internal accounting softuare, versus Excel spreadsheels.
lmplemented timely forecasting of debt covenants (i.e. operating ratio, debt service
coverage ratio and days cash on hand).
Reviewed revenues and expensgs from a number of perspectives including exception
reporting and the timely preparation and review of cost per resident day and variance
reporting,
Reviewed and implemented entrance fee pricing based on actuarial information
combined with market considerations.
Reviewed the resident service agreement and implemented recommendations such
as the transfer policy between units, and waiting list protocols and priorities based on
internal versus external requests.

J:/State of Vermont/$tatement of Qwlifi cations

 r0

SAK Management Services, LLC.

Operational Consultant, Hired By
80-Bed Medicare SNF
fO Personal Care APattments
40 Residential Villas
247 Resldential Apartnents
Berks County, PA

Propefi Owner GrouplLessor'GCRC

SAK was engaged to conduct an operational assessrnent associated with performance
improvemenianO quality care. A comprehensive operational review and assessment of
all departments was conducted to promote opportunities for revenues enhancement, cost
containment and quality assurance.

An operational assessment report of approximately 120 pages was prepared

and
reviewed with management and the Board of Directors. Specific recommendations were
developed to enhance day{o-day operations in each department including in-gervice

training, survey preparedness, QA assessments and operational improvements.
Based on the initial assessment and recommendations, remedial actions included:

Reconfiguration

ol

personal care units

wilh

identification

ol two distinct

neighborhoods.

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lmplernentation of a comprehensive resident assessment process focused on
placement of resident within the continuum based on acuity'
identification of opportunities for enhanced utilization of rehab sbrvices within the
skilled nursing facility.
Review and reconfiguring of maintenance processes and systems resulting in
significant increased efficiencies and strengthened utilization of resources.
proposed addition to resident contracts based on review of the overall market
combined with opportunities for expanded services to residents.
proposed additionalseryice of{erings focused on community based services including
but not limited to home care services.
ldentified significant price savings through independent reviews of pricing such as
supplies.

Revenues en hancement initiatives included:

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Development of an assessment toolto move residents to a higher level of care
Development of a-la-carte service fees for residents requiring additional care
lncrease rehab utilization at the skilled nursing facility.
Aggressively market the ALF to the greater community coupled with a restructuring
and redesign of this operating unit
Aggressively market the SNF {Tracking systems implemented, tour training, guest
relations program, monthly marketing plans with goals, family support groups'
business referral training, etc.)

J:lslatc of VcrmonUslatement of Qualiti$oiions

 SAK Management Services, LLC.

ll

"What if' financial scenarios were prepared based on potential operating results if current
practices remain in place versus implementation of the above recommendations. The
iinancial downside for the next fiscal year if no actions were taken was in excess of $2
rnillion, wlth a similar upside if rec,omrnendations moved forward.
Co ntracted O perati an a I/ Reg u I atoryl F i n a n c i al M a n a g er' CCRC
256-Bed StllF
7I-l!nit, Indepandent Residentlal Ltving / wlth ALF Serulces
Tucson, AZ
Upon SAK'g engagement, this facility was on probation with the state regulatory agency
and featured on the tront page of the local newspaper for abusive treatment of residents
and substandard care of residents. SAK achieved a dramatic improvemenl in the quali$
of care within 90 days. Thereafter, within the first year of operation under new ownership,
the facility received a zero deficiency rating from the state and federal agencies
overseeing the care for residents, The quatity rating established by the state improved
within six months. SAK renegotiated new managed care contracts and received higher
reimbursement based on improved care. Occupancy steadily rose. Medicare certification
for an increase of 12 bedS was implemented. Charge accuracy for therapy and ancillary
revenue, appropriate mark-Ups and inventory accounting were established and
monitored, SAK established a utilization review program to move residents from one level
of care to another in a cost-efficient and quali$ process. Fudher, SAK established
budgetary compliance. Previously, contract nursing ccsts represented $60,000 a month,
anO within three rnonths, SAK eliminated this cost as a result of employee motivation,
improved relations through leadership, and implementation of incentive and benefit
programs.

Operational/Financial Consultant - CCRC
204 Beds, SilF/lCFlMedicarc ALF
6O lndependent Residential Living Coffages
Zionsville,lN
SAK was engaged to evaluate and restructure operations associated with performance
irnprovement and guality care. SAK's priority initiatives included developing directional
strategies for continuity of business interests or alternatively, project disposition. SAK
conducled a comprehensive operational review and assessrnent of alldepartments to
promote opportunities for revenue enhancement, cost containment and quality
assurance. SAK developed specific recommendations to enhance day-today operations
in each department including in-servim training, suryey preparedness, quality assurance
assessments and operational improvements.
Based on SAK'g initial assessment and recommendations, remedial actions included: (i)
resident consolidation and restrusturing of care units; and (ii) closure and relocation of a
specified care unit. The total annual savings resulting frorn implementation of these
recommendatiohs totaled approximately $500,000. Further, SAK's revenue enhancement

J:lState of Vermont/Staternent of Qualifi cstioos

 SAK Management Services, LLC.

t2

initiatives included: (i) development of an assessment tool to move residents to a higher
levef otcare; (ii) aeGnpmeni of a-la-carte service fees for residents requiring additional
of
6re iiiiii."ld"i. of cabacity from 10 to 20 Medicare Beds; (iv) aggressive marketing
(v)
tn.Aii*upled with a'restructuring and redesign of this operating unit;and guest
aggressively marketing the SNF (tracking systems implemented, tour training,
- r"Iitions pr6gram, moitnry marketing plans with goals, family support groups, business
refenaltriiniig, etc.). Thaproject exlieded market expectatione and was successfully
sold as a result of SAK's engagement seruices'

Cantracted O peratlon allRegulatary/F In anei al Manag er
243-bed, Cointy-Awned SNF
Urbana,lL
2fr17, SAK Management Services, LLC was engaged by the Coun$ of
and
Champaign to assurne all general responsibilities related to operational, regulatory
publicly
owned,
(CCNH),-a
HgTe
Nursing
financial iranagement of C-hampaign County
non-ptotitii3-6ed bng-term caie anu rehabilitation facility in urhana. sAK is responsible
ioi pi"nning and shori medium and long-term forecasting and budgeting o! th9 facility's
p"*orrn"nje, working closely with County administration to provide detailed, ongoing
assessments of all aspects of the facility's operation'
wilf'tin OO days of engagement, SAK positively impacted the operations of ccNH in the

ln June

ol

waYs:
following
. Recovered approximately $250,000 in back bills owed the nursing home within the
first 30 daYs of the engagement.
. Nursing abency usagl ivas eliminated by incentivizing current employees to work
shifts Jnd hidng additional staff to fill in open positions'
. n.pfr."d outs-ourced DON and MDS coordinator positions with two experienced
direct hires' alA1o/o savings'
nnrr senrir.es
position with an experient ced direct
Services nnsiiir
. Replaced outsourced Director of Food
hire, improving residents' dining experience'
r Eliminated unnec,essary office overhead.
. participated in collective bargaining discussions for employee wage and benefits
contract renewals within 45 days of the engagement'
. Renegotiated main vendor epntracls within ine tirst S0 days of the.engagement to
improie pricing, payrnent terms and overall quality of goods and services.
. Revlewed exdiing provider contracts and provided recommendations to increase
reimbursement and to secure more favorable payment terms.
. Reviewed current revenues and expenses to optimize them on a per:resident-day

basis.

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goals to
lncreased marketing efforts, hiring a Director of Guest Services and setting
immediately stabilizl census and increase occupancy by 20% within an 18-month
timeframe.
Worked closely with staff to improve CMI and increase the Medicaid reimbursement
rate within the next three quarters.

J:lState of Vcrmont/Statemcnt of Qualifi cations

 SAK Management Services,

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LLC.

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prepared annual budget for the upcoming year along with an additional 3-year
proj'ection based on ai-ready-implemented changes and those scheduled to go into
effectwithin the next 9O daYs.

Allthese initiatives and recommendations saved CCNH $85,000 within the first ninety
days of the engagement, and are on track to hit an impact mark of $900,000 on an
annualized basis.
Op erati on al Assessmen AM DS Revl ew

I 44-bed, for-Profit SNF
Round Lake Beach,lL
In February of 2018, SAK Management Seryices, LLC was engaged by a Skilled
Nursing C6nter to provide an operational assessment with focus in the following areas:

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MDS
PBJ RePorting
Evaluation of Five-Star Quality Reporting
Dietary Services
Resident Activities
SocialServices
Nursing Administration and ClinicalCare

An assessment reirort was prepared and delivered in March of 2018, covering these areas
and a general overview of facili$ operations'

Operatlonal and Financlal Consu ltant
zbo-eed Medicare SNF
'
New York, NY
SAK was engaged by a rnajor non-profit organization to strengthen operations and
dramatically ffirovefinancial performance. ln 60 days, SAK was able to dramatically
improve occupancy trom749/o to 1007o. SAK stabilized localmarket influences and
reierral resouices."SAK maximized Medicare and Medicaid occupancy, while also
initiating a Short Term Therapeutic Rehabilitation Program. SAK stabilized interim
operatiins, maximized interim operating performance and provided in-service training
for improved patient care. SAK initiated budgetary compliance and was su_ccessful in
preserving thb facility's mission and improving the financial performance'of the
organization.

J:lState olVemontlstatcment erf Qrmlifications

 SAK Management Services, LLC.

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State-App ointed Faci lity Iifr onltor
T5,lBed lntermediate Care FacllltY

Shannon,lL
SAK was engaged by the tllinois Department of Public Health to act as a Monitor for this
facilig on Uefiatt of ttie Department. This facility was issued t[ree immediate jeopardies,
there'by threatening loss of funding as well as loss of its licensing and_ceftification'
$AK'singagement included fourdays per week observing all shifts. SAK continued to
provide mlnitoring and recommendations involving all as_pects of facility operations to
ih* govetnment alency. The facility avoided adverse actions and was re-surveyed with
favorable and compliant outcomes'

Regulatory Consultant
224-Bed SNF
Springfield,lL
was in bankruptcy upon SAKs engagement, SAK was engaged by the
This facility'omce
of a large'chiin of skilled nurcing facilities to provide con_sult3tion with
corporate
resiect to impending decertilication and loss of licensure, As a result of SAKs on-site
rnonitoring, in-seMce training, assessments, survey-preparedness, quality assurance
assessmdnts and operationalanalyses, the faciliiy successfully regained certification and
licensure.

CourtAppotnted Speciatisf / lnterlm Cdsis Manager
53 Assisted Living Faeilities
Nationwide
and
economic performance for all 53 facilities during their bankruplcy cases. Unique healthcare
challenges and significant property issues were delegated to SAK. Priority action initiatives
included; responding to immediate facili$ needs; developing and irnplementing initiatives to
stabilize interirn operations and maximize interim operating performance; conducting
property inspections to identis and rectis capital needs and building deficiencies; providing
ior breservahon of thrcatened occupancy; conducting competitive market studies; stabilizing
tocal market influences and referral resources; and performing oversight relating to health
concerns and record keeping. SAK also acted to address short-term cash savings, problems
with overtime and agency usege, survey and licensing issues, and vendor issues such as
engbgement concluded concunently with confirmation of a plan
COD requirements.
of reorganization. Ultimalely, a successful sale of the properties was closed'

$AK was appointed to oversee and monitor resident care, regulatory compliance

bnft

Fi nanciat Advisor to Seculed Creditor
Six,4ssisfed Living / Memory Cars Facilities

Michlgan
SAK was engaged by the secured creditor as financial advisor to review statements and
make recommendations on the operations for six assisted living facilities (380 total

J:/State of Vermontlslalemsnt of Qualifi cations

 SAK Management Services, LLC,

l5

units) in Michigan. After two months, while in forbearance, the Debtor voluntarily
engaged SAK to manage the facilities" Prior to SAK's involvement in March, EBITDAR
tor tne six properties reflected $67,000 per month. ln November, under SAK's interim
management, EBITDAR for five of the properties reflected over $155,000 per month,
and one outlying properly was sold to a local provider. To achieve this turnaround, SAK
utilized revenue enhancement initiatives and implemented cost contiainrnent control
measures to emerge from forbearance. SAK's priority action initiatives included
conducting in-service training to all staff; improving in-patient care areas and operating
efficiencies; developing staffing and supply budgets; implementing best policies and
procedures for cash management, reconciling revenue journals and master census
reports to achieve more accurate revenue recognition, decreasing operating expense
balances; and initiating more efficient procedures to provide daily census to prornote
optimalaccounting with respect to the revenues, billing and accounts receivable
functions. SAK also reviewed and updated accounts receivable collection policies and
procedures, including contracting with lower cost aggressive collection agencies and
attorneys, and cornpleted resident ensus reconciliation daily and monthly.freventaiive
maintenance practices were reviewed and evaluated at all of the facilities. Finally, SAK
overhauled and improved marketing and census development action plans.

JJState of Yerrnont/Statemcnt of Qualifications

 SAK Management Services, LLC

l6

sAK PROFESSIpNAL PROFILES
SUZANNE KOENIG
Suzanne Koenig is president and founder of SAK Management Seruices LLC, a nationally
recognized tong+eim care management and consulting services company. As owner and
operitor of SAK for over 20 years, Ms. Koenig provides a highly specialized combination
oiskills in the areas of operations improvement, staff development and quality assurance.
Her meticulous precision in marketing and census development within the Senior Housing
and long-term care industry offers operation enhancements few others can matchAs a direct owner and operator, Ms. Koenig offers the practical perspective of the
challenges and opportunities confronting long-term care providers in rnanaging the
industryls changing'dynamics. She is a Licensed Nursing Home Administrator and a
ticensed SocialWorXer in multiple states, and her professional experience includes.

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Executive positions ln marketing, development and operations management for
both regional and national health care providers repre$enting properly portfolios
throughout the country.

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Recent appointments as Receiver, Examiner, Chapter 11 Trustee and the Patient
Care Ombudsrnan in several of the new Health Care Bankruptcy Filings (Chapter
11 and Chapter 7) with the advent of the (BAPCPA) Bankruptcy Abuse
prevention and Consumer Protection Act of 2005 including Health Care Entities
such as: Physician Practices and Hospitals - she is the most frequent courtappointed Patient Care Ombudsman to medicalfacilities, advocating for patient
care, in the country.

r

Board Mernber on several organizatlons that provide education and expertise to
the Healthcare lndustry

r

Management roles with over 500 facilities, providing the in-house management to
restore care and fiscal soundness, while establishing administrative teams that
lead each facilitY to recovery.

r

Service in an advisory and consulting capacity for numerous client engagements
involving bankruptcy proceedings as well as in tumaround management
situations.

t-

Proven proficiency in maxirnizing financial return and cash flow, while
maintaining the highest standards of patient care:

J:/State of Vemront/Statemenl of Qualifi cations

 SAK Management Services, LLC.

l7

Other notable career achievements include the following:
Ms. Koenig serves on the Board of Directors of the Summit Healthcare REIT,
lnc,; she was recently elected to the GlobalTurnaround Management
Association Board of Trustee; and serves on the Board of Directors for the
Schoolof SocialWork at the University of .lllinois, Champaign-Urbana.

)

She serveS as an Officer and Director for several long-term care provider
associations; Ms. Koenig is Co-Chair of the American Bankruptcy lnstitute's (ABl)
Heatth Care lnsolvency bommittee and Co- Chair for the Steering Cornmittee of
the Midwest Turnaround Management Association (TMA) Chapter.

l

She served on the Negotiating Team Task Force in Arizona, designing and
negotiating the contrait between the State and Counties for delivery of lndigent
Health Services.

r

The only non-Lawyer and non-Attorney General invited by th9 \11oL.t .
Associaiion of Attorney Generals to participate on a panel, titled "Patient Care
Ombudsman" addressing the Patient eare Ombudsman's interaction with the
States in their role as Patient Care Regulator.

r

Testified before the House of Representatives as the lndustry Expert in Funding
the Long Term Care lndustry'

Ms. Koenig holds a Master of Science Degree from Spertus.Colle.ge, lllinois, and a
Bachelor Jf Social Work Degree from the University of lllinois, Champaign-Urbana,
lllinois. She is a frequent speaker for various healthcare industry associations and
business affiliates where she conducts continuing education and training programs'

phases
Suzanne Koenig and SAK have earned the reputation as lndustry Specialists in all
spent
have
and
experience,
ye?rs
collective
250
of long term care operations, having over
To
facilities.
troubled
rescuing
a targ; portion of iheir €reers in iurn-around situations,
today.
SAK
putii-ot-"lrss Turnaround Services in place at your healthcare facility contact

SAK,s combined collection of knowtedge and expertise is unmatched in the industry;
please take a few minutes to meet the members of our highly-qualified and dedicated
staff.

FLORA REZNIK, Chief Flnancial Offlcer
Ms. Reznik has served as the Chief Financial Officer of Skilled Nursing Facilities with
multi-site rnulti-state organizations in lllinois, lndiana and Tennessee bygrowing portfolios
of skilled nursing facilities. Ms. Reznik has extensive experience in acquisitions, mergers,
take-overs andlurnarounds, pre-opening and transition costs, due diligence, financial
planning and budget forecasting. She handles various restructuring projects, develops

J:/Slate of vemont/Statcmenl (,1'Qtjalifications

 SAK Management Services, LLC

l8

departments in newly-expanded geographic areas, establishes purchasing and eprocurement processes to bring the most optimized pricing solutions to managed
facilities, negotiates vendor contracts and office solutions. She manages investrents,
treasury and cash operations of the multi-segmented companies
Ms. Reznik has negotialed and secured ABL and working capital financing for facilities
along with covenant compliance that is optimal for facilities based on their financial
performance" She works directly with various lenders, RElTs, HUD, private and equity
investors. Ms. Reznik negotiates Managed Care contracts to secure maximized
reimbursement and payment terms to the managed facilities and works with insurance
companies' project managers to guarantee timely payments for services provided by
facilities. She works directly with various financial institutions to secure corporate credit
card programs to extend vendor payment terms. Ms. Reznik was involved in accounting
software conversions of various organizations multiple times guaranteeing the most cost
effective solution. Ms. Reznik directly manages Accounting and Treasury Managemenl,
AlP, Purchasing, Payroll and Benefits, lT, Collections and A/R departments. She is
responsible for process improvements and policy development. She offers a hands-on
approach to assure her team delivers best services to managed facilities.

Ms. Reznik has a BS in Accounting from DeVry University and MAFM from Keller
Graduate School of Management. She is a Member of the HFMA (Healthcare Financial
Management Association), an Afiiliate Member of ICPA and a member of the Chicago
CFO Leadership Council.
JOYCE CIYOU, MS, RN, LHFA, CLNC, Chlef Operatlng Officer
Joyce Ciyou has extensive hospital and senior living managernent expertise from bedside
nursing to administrative management and leadership roles in a variety of Healthcare
Settings; this wide spectrum of experience provides Ms. Ciyou with the ability 1o solve
problems that impact a varie$ of Administrative and Clinical operational palhs. She
maneuvers easily through the various layers of the acute and post-acute continuum of
care.

As a Licensed Nursing Home Administrator, Ms. Ciyou guides the operatione of the longterm care environment through her extensive background as Licensed Nursing Home
Administrator, Director ol Nursing and several Nursing Quality Positions. She holds a
degree in Gerontology and understands the complex medical conditions of the older adult.
Ms. Ciyou has vast experience in setting up productive communication and team building
systems with all layers of staff in the post-acute care setting. Ms. Ciyou has the expertise
to bring a facility into financial and regulatory compliance.

As a Certified Legal Nurse Consultant {CLNC} and Certified Case Manager {CCM), Ms.
Ciyou knows the value of the team approach to problem solving. She strives to work with
others in order to bring about resolution to difficult situations. Her Master's Degree in
Organizational Management better enables her to understand the business operations of
both the acute and chronic care seftings. Ms. Ciyou is a Registered Nurse and a Licensed

J.lState of VcnnontrStatement olQualifi catrorn

 SAK Management $ervices, LLC.

l9

Nursing Home Administrator in the states of lllinois and lndiana and a Certified Wound
Specialist,
KEITH HUF$EY, Dlrector of Operatlons
With 30 years'experience working in the long term care industry Keith HufseY Provides
SAK and our clients with a wealth of knowledge and experience. As the Director of
Operations he is involved with the overall operation in all facilities and plays an
instrumental role in the turnaround of deficient facilities'
Over his career Keith has accumulated a number of deficiency free $uryeys, which speak
to his ability to deliver results, and has maintained major involvement in assisting the
turnaround of deficient nursing homes into operationally sound facilities.

Keith's input and operational involvement include the benefit of his experience in various
facets of the long-term care industry as well as other related fields. The value he brings
to every client includes knowledge that stems from being a Licensed Nursing l'lome
Administrator for over 25 year$. His expertise of writing Plans of Correction for
government approval and State licensut:e and Federal certification is unmatched. He
iarries a Food Service Certification and is a Licensed Practical Nurse in lllinois and a
Certified Trustee to a multi-million dollar religious organization'
L. KEMPINERS - Health Care Policy and Regulatory $peclallst
I
Kempiners has been involved with health care public policy, regulatory and
Iffiffirsement
issues for rnore th'an 30 years, He was a four-term rnernber of the lllinois

House of Representatives, the Director of Public Health for lllinois, and the Executive
Director of the lllinois Health Care Association, a trade group composed of nearly 500
licensed geriatrie long-term care facilities, skilled pediatric facilities, assisted living and
supportivi living facilities, and facilities and programs for the developmentally disabled,
foi nearly 1S yebrs. Mr. Kempiners participated in the development of the lllinois Nurcing
Home iare Act of 1979, and that Same year resigned his seat in the House of
Representatives to become the Director of Public Heatth for lllinois. As the Director he
was responsible for a wide variety of health promotion, regulation, funding and planning
programs with an annual budget ol $127 million.
While Director of Public Health, Mr. Kempiners was appointed to the National Committee
on Vital and Health Statistics (U.S, Department of Health and Human Services) and the
Advisory Committee to the Women, lnfants and Children's Advisory Committee {U. S.
Department of Agriculture). He served on the Association of State and Territorial Health
Officials (ASTHO) Executive Committee and chaired several committees, requiring him
to present testimony before committebs of the U. S. Senate and House of
Representatives.

J:/Statc of VermonVstatemont of Qualifi cations

 7A

SAK Management Services, LLC.

During his tenure at IHCA, Mr. Kempiners actively pailicipated in a varie$ of activities
anO iommittees of the American Health Care Association and National Center for
niiirtro Living. There are few other professionals with his acute understanding of public
policy and itg impact on longterm health careTAMttllE DENNING, Gllnical and Administratlve Nursing Speciallat.
Ms. Denning has 25 years' experience in Long-Term C91e, with two decades of that in
the role of Director of Nursing. She is a Licensed Nursing Home Administrator, ln addition,
she has 10 years of expeiience in the emergency room, Her varied and extensive
eiperience aliows Ms" Denning to holistically asiess facility programs and ensure that all
necessary changes are made to meet the most current regulatory and clinical
requirbmints. She carries a certificate of Antibiotic Stewardship'
LORETTA PRICE, MDS/Relmbursement Specialist
Lorefta price has over 30 years of experience in the Post-Acute Care Environment and
MDS
ZO yeirs of experience in ine reimbuisernent field. As an experienced Nurse.and
tOt Care Plan lnstructor, Ms. Price's clinicalskills have proven results in developing
"nO
individual methodologies for each facility to maximize reimbursement through
documentation and thiassessment process. She is also confident in her skills to consult,
train/educate the IDT team members on the MDS completion, submissions' and
restorative programming. Ms. Price oversees, teaches, and trains MDS coordinators and
IDT team members o-n accuracy of assessment, CAA, Care Plan completion and
restorative programming, she educates all levels of nursing staff on regulatorysurve! techniques. Ms. Prie develops and implements Plans of
t"qlir"r"ntl
of
"iO
corrections for survey ciiations and provides Direct In-services to staff for the Plan
nursing
the
to
resource
process.
valuable
Ms. Frice is a strong asset and
Care
component while focusing on financially attributed programming,
.

Ms. price understands the significanc€ of quality assurance. Her effectiveness

in

gitnering and assessing information, developing action.plans for targeted and potentially
Her constructive focus is not only
iiorr"ritic areas haviresulted in positive outcomes.
on outstanding Medicaid accounts, Demand Billing Requests, and Medicare Additional
lnformation Requests but also focuses on monthly Medicare Billing'
Ms. price is overly capable of working self-guided as an efiective team inember in a fastpaced and ever changing environment'

J:/Sta1e of Vermortfstotcment of Quslilications

 SAK Management Services, LLG.

2t

TERRI R. SHERMAN, CPA - Flnance Specialist

Terri Sherman has over 15 years'experience in the healthcare industry

including
years
she was
significant experience in longterm care and retirement housing. For eight
the Chief Financial Officer/Comptroller of a rnajor senior health system located in the
Lower Hudson Valley of New York providing the financial leadership forover 300 nursing
home beds, 300 assisted living beds, a 163-unit continuing care retirement community as
well as a licensed home health agency, a managed long term care program, adult day
care and many community outreach programs.

Terri is experienced in the preparation of financial feasibility studies, third party
reimbursement issues, operational audits and re-engineering system reviews. She's
conducted financial analysis of merger and acquisition transactions and productivity
reviews, as wettas strategic planning sessions and is experienced in the developrnent of
managed care contracting and reporting arrangements.

Terri is a member of the New York Association of Homes and Services for the Aging
(NY,AHSA), the Healthcare Financial Management Association (HFMA), and the
American Association of Homes and Services for the Aging (AAHSA). She is an
accomplished presenter on relevant topics affecting skilled nursing provider
reimbursement. Terri is a graduate of Northeastern University in Boston, Massachusetts,
with a Bachelor of $cience in Accounting. $he holds a Certificate in Managed Care from
Rutgers University and a Certificate in Senior Housing Development and Finance from
Johns Hopkins University graduate school. Terri is a member of the New York State.
MICHELLE MCDONALD - Administrative and Senior Nurse Specialist
Michelle McDonald has over 20 years in the long-term care and public health industry.
the is an experienced New York State Licensed Nursing Home Administrator and
registered nurse, and a nationally recognized expert in quality initiatives in skilled nursing
facitities. Currently Ms. McDonald is a project leader in the current CM$ initiative to
compare and review federal and state survey processes.
Recently.Michelle was the project manager for the _Cgnter of Medicare and Medicaid
Services'' (CMS) Data Assessment and Verification {DAVE) contract, and as such is an
expert in the accurate preparation of the Multiple Data Assessment (MDS) tool. Michelle
is experienced in the Joint Committee for the Accreditation of Hospital Organizations
(JCAHO) process, and implemented care management programs in acute, post-aeute
and in community seltings. Michelle has participated in numerous New York State
"Nursing Home surveys and has conducted mock surveys throughout the State. Other
credentials and notable accomplishments include:

.

Recipient of the Ralph J. Barron Scholarship/Grant awarded by the NY State Chaptef
of the Amedcan College of Health Care Administrators

J:/Statt of VermontiStatenent of Qualifications

 SAK Managernent Services, LLC

a

.,1

Recipient of the Joint Gornmission Resource Discretionary Award for outstanding
performance in project management
A master's degree in public health policy and management from New York Medical
College, Valhalla, New York
Undergraduate degree in nursing from Mount Saint Mary College in Newburgh, New
Yod<

I

a
a

Membership in the American College of Health Care Administrators, and the New York
State and American Nurses Associations
Chairperson of the Utilization Review Committee, the Professional Advisory
Committee, the Charting and Documentation committee and the Community Service
committee for the Orange County Department of Health
Accomplished speaker and'trainer in Survey readiness, RAl, RAPS and Care planning
Society of CPA's and the American lnstitute of CPA's.

CHRISTINE O'TOOLE

-

Clinical Nurslng Specialist

Christine O'Toole is an accomplished clinician and nursing expert, with 25 years of
nursing services primarily in the long{erm care industry. ln her tenure as Director of
Nursin-g for nursing homes in the lower Hudson valley region of New York she maintained
deficiency free homes, and is accomplished in writing statements of deficiencies and
plans of correction.

She is certified to perform Patient Review and Screen lnstruments, and

conducts
statewide reviews and training, Christine is an expert in the design of efficient nursing
staffing patterns to ensure quality of care and cost effectiveness. She developed new
inltiatives in the area of pain management in skiUed nursing facilities and continues to be
in the forefront of implementing innovative policies to ensure patient satisfaction and

clinical effectiveness.

Christine is a licensed New York State Nursing Home Administrator, and a Registered
Nurse. She is a graduate of St. Josephs College with a Bachelor in Health Care
Adminietration, and is pursuing her graduate degree in healfi care administration from
$t. Josephs College in Maine.
KELSEY SCHWARTZ - Admlnlstrative end Senior Nurse Specialist
Kelsey Schwartz is a leader. She guides interdisciplinary teams in working with health
care facilities in regulatory crisis, interim management, state appointed management
and educational programming in an effort to bring about positive and lasting change.
ln the past 20 years Ms. Schwartz has worked with over 300 long-term care facilities and
is a recognized expert in the regulatory process. She is skilled at assisting facilities
improve cbre while consolidating costs, and her method of developing and implementing
J:/Slale of Vcrmont/Statement of Qrralifications

 SAK Management Services, LLC.

23

systems in long-term care has assisted facilities to achieve and maintain compliance long
after the survey is over.

Kelsey is acknowledged nationally as an expert in quality assurance programming,
management and system developrnent, Medicare reimbursement and the Resident
Assessment lnstrument, and frequently asked to speak on these subjects at industry
gatherings. Her credentials and other notable accomplishments include;

".
.
r
.
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Licensed Nursing Home Administrator and a Registered Nurse in Michigan
Certified in Gerontology and Case Management
Served as Executive Director, Administrator, Dir. of Nursing in long term care facilities
Certified remediator for the Michigan Public Health lnstitute
Author of "The Abuse Prohibition Manual" published by the Briggs Corporation
Frequent contributor to the Post-Acute Payment Report

LINDA L. SAUNDERS - Admlnlstrative Census Development Specialist

A Licensed Nursing Home Administrator for 20 years, Linda Saunders' specialization in
opening new facilities (long term care, continuing care retirement communities, assisted
living projects) has developed facility based leadenhip teams and spearheaded
aggressive marketing programs that exceed occupancy goals and profit expectations.
Deficiency free surueys, high resident satisfaction scores and JACHO accreditation with
commendation at the facilities for which she has worked highlight Ms, Saunders'
commitment to high quality resident care.

Ms. Saunders was the Vice President of Business Development for an Ohio based
rehabilitation services company that while under her leadership experienced 400%
growth in 3 years. Her unique blend of administrative skills coupled with tenacious
marketing expertise advanced her success as a mentor in the health care arena;
consulting to a number of national long'term care companies in the areas of marketing,
customer service and managed care contracting, while developing specialty and subacute units,
A Licensed Nursing Home Administrator in the State of Ohio, in 1999 Linda was awarded
the "Marketing Tool of the Year Award" by The Heatth Care Admissions and Marketing
Directors Association of America. She is an active member of the Ohio Health Care
Association, The Ohio Academy of Nursing Homes, The American College of Health Care
Administrators and The Case Management Society of America, and a frequently sought
keynote speaker.

TERRTMCINTOSH

- Registered

Health lnformatlon Technician (RHIT) Specialist

Terry is an AHIMA credentialed professionalwho is both a Registered Health lnformation
Technician and Certified Coding Specialist. She has over twenty years' experience in
J:/State of Vermon/Statement of Qualifi cations

 SAK Management Services, LLC.

24

medical record auditing and coding. Terri is a University of Detroit-Mercy graduate with a
degree in Health lnformation Technology.

Terri began her career at St. John Hospital and Medical Center in Detroit, Michigan as
Assistanl Manager in Utilization Management, where she also served as Committee
Assistant to the Surgery Quality Assurance Comrnittee. From there she moved into the
consulting arena and has consulted in all areas of healthcare including acute care, post:
acute care, physician practice, clinic and psychiatric facilities.

Specializing

in coding compliance, Terri has assisted many Health lnformation

Management departments with process improvement as it pertains to Revenue Cycle and
Reimdursement. She has assisted Patient Accounts departrrents with denial
management and revenue recovery. Teni has also served in many interim HIM
rnanagement Positions

HELEN FIGUEROA, Offlce Manager' Paralegal
Helen Figueroa is an experienced office manager and paralegal with over 30 years in the
field of i-aw, insurance and banking. Ms. Kouis oversees, organizes, evaluates and
delegates all dayto{ay office management operations and procedures. She will monitor,
reviJw, record,-maintain and prioritize all workman's compensation clainis, resident
incident repOrts, DON repOrts, complaints, surveyS, wound reports, new admissions,
census, death dossiers, lawsuits and legal documentation. She will monitor, oversee,
maintain and fotlow-up on various criteria with the insurgnce companies. She will work
closely with the SAK team and provide support as needed

J:lState of Vermont/Statement o{ Qurlilications

 SAK Management Services, LLC.

25

CAPABILITIES AND RESOURCES
SAK and its affiliates have been providing management and support services in the long
term care field for over 30 Years.
.

SAK's associates have over 250 years collective experience in all phases of long term
care operations, and have spent a large portion of their long-term care careers in tumaround situations, rescuing iroubled ficilities. The team provides a complete range of
management services andexpertise necessary to create,facilities, which will operate at
tne o$iimum levelfrom both a financialand care perspective. We concentrate on daytoday operations including:

r
r
.
.
.
.
.
.

Regulatory ComPliance
Staff Training and Retention
Resident Care
Census Development
Community Relations
Financial Reporting
Resident Services
Resident and Family Satisfaction

'
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.
r
.
r

Psychological Care and
Programming
Physical Plant Maintenance
Accounting and Bookkeeping
Asset and Cash Management
lmprovingThird-Party
Reimbursement
UpgradingFinancialPerformance
(Profit Making)

WORKOUTS

Savlng Poor.Performlno Fasllities

SAK has extensive experience in multi-state operations, and employs professionals

experienced in managing situations unique to the Seniors Housing and Care lndustry.

SAK's greatest strengths lie in the quality and dedication of its associates, whose "hands
on sgl6" is especially geared to mid-sized fecilities, where personal involvement is an
essential ingredient in motivating and leading staff to hlgher levels of perforrnance' The
SAK team, 6y virtue of its past performance, has established its ability a.nd rea.diness to
take on and successfully address problems of long-term care facilities in States
demanding tight regulatory compliance and require operating efficiencies.

J:/State of Vermqnt/Statement of Qualitications